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DESCRIPTION  OF  PLATE  I 

P.  N.     Anterior  Palatine  Nerve. 

P.  A.     Greater  Palatine  Artery. 

P.  V.     Palatine  Vein. 

P.     Periosteum. 

P.  R.     Palatine  Rugaj. 

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T.  of  T.  V.  P.     Tendon  of  Tensor  Veli  Palatini. 

M.B.     M.  Buccinnator. 

I.  F.  of  P.  M.     Interlacing  Fibers  of  the  Palatine  Muscles. 

P.  M.  R.     Pterygomandibular  Raphe. 

M.C.  P.     M.Cephalopharyngeus. 

M.  P.  P.    M.  Pharyngopalatinus. 

M.  G.  P.     M.  Glossopalatinus. 

P.  T.     Palatine  Tonsils. 

M.G.     Molar  Glands. 

D.  S.  A.  F.  P.  P.     Deep  Surface  of  the  Anterior  Fasciculus  of  the  Pharyngopalatinus. 

L.  V.  P.     Levator  Veli  Palatini. 

P.  F.  P.  P.     Posterior  Fasciculus  of  the  Pharyngopalatinus. 

S.  P.     Salpingopharyngeus. 

A.  F.  P.  P.     Anterior  Fasciculus  of  the  Pharyngopalatinus. 

M.  S.  of  T.     Median  Sulcus  of  the  Tongue. 

C.  P.     Circumvallate  Papilla}. 

Fgf .  P.     Fungiform  Papillie. 

Fol.  P.     Foliate  Papilla?. 

F.  P.     Filiform  Papilla;. 
T.  T.     Tip  of  Tongue. 
TJ.     Uvula. 

I.  F.     Isthmus  of  Fauces. 

P.  P.  A.     Pharyngopalatine  Arch  (Posterior  Pillar  of  the  Fauces). 

G.  P.  A.     Glossopalatine  Arch  (Anterior  Pillar  of  the  Fauces). 


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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
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http://www.archive.org/details/surgeryoforaldisOObrow 


THE  SURGERY 

OF 

ORAL  DISEASES  AND 
MALFORMATIONS 

THEIR  DIAGNOSIS  AND  TREATMENT 


BY 

GEORGE  TAN  INGEN  BROWN. D.D.S..M.D., CM., F.A.C.S. 

MAJOR,    MEDICAL    OFFICERS'    RESERVE    CORPS,    U.    S.    ARMY. 

ORAL    SURGEON    TO    ST.    MARY's    HOSPITAL    AND    TO    THE     CHILDREN'S     FREE    HOSPITAL    AND 

COLUMBIA    HOSPITAL,    MILWAUKEE ;    FELLOW    OF    THE  AMERICAN  MEDICAL  ASSOCIATION ; 

MEMBER    OF    THE    NATIONAL    DENTAL    ASSOCIATION;  CHAIRMAN  OF  THE  SECTION  ON 

ORAL    SURGERY    OF   THE    FOURTH    INTERNATIONAL    DENTAL    CONGRESS,    ETC. 


THIRD  EDITION 


WITH    570   ENGRAVINGS  AND  20   PLATES,  AND   A   SELECTED   LIST   OF 
EXAMINATION   QUESTIONS 


LEA  &   FEBIGER 

PHILADELPHIA     AND     NEW    YORK 


^\  .-J'  2i  ■  T> 


\ 


Copyright 

LEA  &  FEBIGER 

191S 


3  5  2-3 

'  \'h\% 


TO  . 
EMILY  LYNCH  BROWN 

MY   MOTHER 
AND 

ELIZABETH  KATHLEEN  SELBY  BROWN 

MY    WIFE 


PREFACE  TO  THE  THIRD  EDITION. 


The  most  important  changes  in  this,  the  third  edition,  of  this 
work  are  to  be  found  in  the  chapter  relating  to  war  surgery. 

Hitherto  undreamed-of  mutilations  of  jaws  and  faces  by  high 
explosives  in  this  war  have  necessitated  many  radical  changes  in  the 
methods  of  mimediate  treatment  of  these  war  injuries. 

In  natural  sequence  has  also  come  the  elaboration  and  the  execu- 
tion of  many  wonderful  surgical  plastic  operations  and  prosthetic 
devices  for  the  reconstruction  and  rehabilitation  of  these  honorably 
deformed  and  battle-scarred  individuals. 

Oral  and  plastic  surgery  as  recognized  by  the  Surgeon-General  of 
the  United  States  Army  promises  great  achievement  for  the  allevia- 
tion of  these  distressing  conditions,  and  it  is  evident  that  the  associa- 
tion of  surgeons  and  dentists  thus  created  for  the  prosecution  of  this 
work  must  require  an  extensive  knowledge  on  the  part  of  each  of  the 
possibilities  for  good  accomplishment  of  the  methods  of  the  other  in 
order  that  through  complete  cooperation  the  best  results  may  be 
secured. 

To  meet  this  situation  the  author  has  endea^'ored  to  gather  together 
representative  ideas  and  methods  as  published  from  the  work  of  the 
hospitals  of  practically  all  the  principal  nations  now  doing  battle. 

Large  numbers  of  illustrations  have  been  added  to  show  desirable 
selections  from  an  almost  unlimited  variety  of  splints  that  have  been 
constructed  along  the  Imes  of  well-known  fixation  devices  for  securing 
fractured  jaws,  such  as  were  illustrated  and  described  in  the  previous 
editions,  but  in  many  cases  so  improved  as  to  be  capable  of  much 
wider  usefulness  than  the  earlier  models. 

^Yith  each  succeeding  edition  the  author  feels  more  deeply  a  sense 
of  appreciation  of  the  Aalue  of  the  assistance  rendered  by  those  whose 
names  have  been  mentioned  in  the  prefaces  for  the  first  and  second 
editions,  all  of  whom  he  again  thanks  most  sincerely. 

At  this  time  acknowledgment  is  also  due  to  Joseph  C.  Beck,  ]\I.D., 
F.A.C.S.,   of    Chicago,   Professor    of    OtolarjTigology,   University  of 

(v) 


vi  FREFACE  TO  THE  THIRD  EDITION 

Illinois,  for  the  illustrations  of  his  demonstrations  on  the  cadaver 
that  were  given  for  the  army  schools  of  oral  and  plastic  surgery  at 
St.  Louis  and  Chicago,  and  to  Major  Robert  H.  Ivy  for  courteous 
assistance. 

A  final  tribute  is  due  to  all  the  men  of  genius  in  the  belligerent 
countries  whose  faithful  devotion  has  served  to  make  oral  surgery 
and  prosthesis  useful  beyond  belief.  To  each  and  every  one  of  these 
workers,  no  matter  where  his  abilities  may  have  been  exercised  in 
behalf  of  wounded  men,  the  obligation  for  records  of  the  advancement 
of  this  science  is  sincerely  acknowledged,  with  regret  that  it  is  not 
possible  to  mention  by  name  each  of  the  illustrious  contributors. 

G.  V.  I.  B. 

Milwaukee,  1918. 


PREFACE  TO  THE  SECOND  EDITION. 


In  this  the  second  edition  of  this  work  the  author  has  found  it 
necessary  to  make  many  revisions  and  additions  in  order  to  keep  pace 
with  the  great  strides  forward  that  have  been  made  in  the  surgery  of 
oral  diseases  and  deformities  since  the  first  edition  was  pubUshed. 

This  was  found  to  be  particularly  true  with  regard  to  conductive 
anesthesia,  focal  infection  of  oral  origin  and  maxillary  expansion  for 
the  relief  of  nasal,  nervous,  mental,  bronchial  and  other  disorders. 

The  etiology  and  treatment  of  infectious  diseases  and  neoplasms; 
methods  for  the  deep  injection  of  the  trigeminal  nerve  at  the  foramen 
ovale,  the  foramen  rotundum,  and  the  Gasserian  ganglion  also  required 
more  complete  elaboration  in  view  of  recent  advancements. 

The  casualties  of  the  world  war  made  necessary  an  extension  of  the 
description  of  the  methods  of  operative  treatment  of  fractures,  resec- 
tions of  the  jaws  and  other  mandibular  affections,  as  well  as  for  the 
treatment  of  wounds  under  war  conditions. 

The  chapters  on  Harelip  and  Cleft  Palate  reflect  the  improvements 
that  are  the  natural  result  of  the  growth  of  the  author's  widening 
experience  in  this  special  operative  field. 

For  teachers  and  students  the  list  of  examination  questions  will  be 
found  to  be  an  inestunable  advantage,  inasmuch  as  the  chapters  and 
headings  in  the  text  correspond  to  the  grouping  of  the  questions. 
These  may  be  followed  in  outlining  lectures  and  also  for  examination 
purposes,  with  much  convenience  both  to  lecturers  and  students. 

To  all  who  aided  in  the  production  of  the  first  edition  and  all  those 
whose  researches  and  writings  have  been  utilized  in  quotations  or 
otherwise  the  author  again  extends  sincere  expressions  of  appreciation. 

With  particular  reference  to  this  second  edition  the  author  is  indebted 
to  Dr.  0.  H.  Foerster,  of  Milwaukee,  for  revision  of  the  chapters  on 
Diseases  of  the  Mucous  Membrane  of  the  Mouth  and  Syphilis;  to 
Dr.  Francis  J.  Wilson,  of  Paris,  formerly  of  the  American  Ambulance 
Hospital  (B.  at  Juilly),  France;  Dr.  George  B.  Hayes  and  Dr.  William 
S.  Davenport,  of  the  American  Ambulance  Hospital,  Neuilly  (Paris), 

(vii) 


vm  PREFACE  TO  THE  SECOND  EDITION 

France;  Dr.  Edward  C.  Kirk,  editor  of  the  Dental  Cosmos;  Dr.  Joseph 
Rilus  Eastman,  Indianapolis,  Ind.,  formerly  chief  surgeon,  Reserve 
Hospital  No.  8,  Vienna,  Austria;  Dr.  George  E.  Meyer,  of  Chicago, 
111.,  Major,  R.  A.  M.  C,  formerly  Oral  Surgeon  of  the  Twenty-third 
General  Hospital,  British  Expeditionary  Force,  France,  and  Captain 
S.  D.  Boak,  D.S.C.,  Columbus  Barracks,  Columbus,  Ohio,  for  original 
contributions  and  assistance  in  the  preparation  of  the  chapter  on  the 
Treatment  of  Wounds  under  War  Conditions;  to  Dr.  Sheppard  W. 
Foster,  of  Atlanta,  Ga.,  for  much  clinical  illustrative  material;  to  Dr. 
Albert  J.  Ochsner,  of  Chicago,  and  Drs.  Edward  S.  Judd  and  Gordon 
New,  of  the  Mayo  Clinic,  Rochester,  Minn.;  Dr.  Fred  H.  Albee,  of 
New  York,  Dr.  Vida  A.  Latham  and  Dr.  Eugene  S.  Talbot,  of  Chicago, 
for  valuable  illustrations  and  descriptions  of  interesting  cases. 

A  special  word  of  thanks  is  also  due  to  Dr.  George  A.  Harlow,  of 
Milwaukee,  whose  advice  and  efficient  cooperation  in  conducting 
army  examinations  went  far  toward  making  possible  the  completion 
of  this  work  under  present  conditions,  and  to  Dr.  Selby  Van  Ingen 
Brown  for  additional  assistance  of  this  character. 

G.  V.  I.  B. 

Milwaukee,  1917. 


PREFACE  TO  THE  FIRST  EDITION. 


In  the  preparation  of  this  work  the  author  has  endeavored  to  meet 
certain  demands  the  urgency  of  which  has  been  borne  in  upon  his 
mind  after  more  than  thirty  years'  experience  in  the  treatment  of 
oral  diseases  and  malfonnations.  During  the  last  ten  years  of  this 
period  his  practice  has  been  limited  to  these  affections.  Through 
frequent  consultations  and  cooperation  in  the  treatment  of  patients 
who  have  been  referred,  he  has  been  closely  in  touch  with  dentists, 
general  surgeons,  internists  and  those  whose  practices  have  been 
limited  to  rhinology,  ophthalmology,  otology,  pediatry,  dermatology 
and  other  divisions  of  medical  practice.  This  volume  is  therefore 
designed  to  be  a  book  of  reference  touching  all  these  medical  interests 
in  their  oral  relation. 

As  a  teacher  of  oral  surgery  he  has  also  become  convinced  that 
for  many  reasons  there  is  great  need  of  a  text-book  adapted  to  both 
didactic  and  recitational  instruction  on  this  subject,  sufficiently  con- 
cise and  well  systematized  to  permit  of  accommodation  of  the  course 
to  the  stringent  time  limitations  of  a  college  curriculum  and  yet 
impressing  the  salient  points  to  the  best  possible  advantage,  and  so 
arranged  as  to  facilitate  the  u'ork  of  students  in  preparing  themselves 
for  examination.  While  meeting  these  requirements  it  is  believed 
that  this  work  is  sufficiently  comprehensive  and  practical  to  make  it 
a  useful  guide  in  trying  clinical  situations  after  graduation. 

The  chapters  on  Harelip  and  Cleft  Palate  represent  the  chief  part 
of  the  author's  life  work.  His  conception  of  the  presentation  of  the 
subjects  is  based  upon  extended  observation  of  the  confusing  condi- 
tions which  surround  those  who  are  called  upon  to  treat  such  cases 
in  the  course  of  general  practice.  There  is  much  diversity  of  opinion 
among  writers  as  to  the  best  methods  of  procedure,  and  the  ill  results 
of  a  wrong  step  in  treatment  are  great  and  long  continued.  The 
clinical  aspect  has  been  kept  constantly  in  view  in  order  to  provide  a 
dependable  source  of  information.  ]\Iany  original  drawings  have 
been  carefully  prepared  to  show  each  operative  step  in  the  correction 

(ix) 


X  PREFACE  TO  THE  FIRST  EDITION 

of  these  deformities.  Much  space  has  been  given  to  the  explanation 
of  operative  methods  and  the  underlying  factors  which  influence 
results.  The  pictures  of  large  numbers  of  patients  are  shown  in  order 
to  emphasize  the  thoroughly  practical  clinical  value  of  operations 
and  corrective  measures  that  are  recommended.  These  are  in  the 
form  of  engravings  made  from  photographs.  They  are  therefore  true 
examples  of  the  results  of  treatment  which  is  in  harmony  with  the 
developmental  principles  that  govern  facial  symmetry,  speech  func- 
tion and  nasal  form.  Upon  these  influences  also  depend  freedom 
from  nasal  disease  and  other  more  widely  distributed  affections,  both 
general  and  local.  All  illustrations  except  those  credited  to  other 
writers  are  representations  of  the  author's  cases. 

It  is  well  kno^\Ti  that  grave  consequences  might  often  be  avoided 
by  the  early  detection  and  correction  of  quite  simple  mouth  diseases. 
Too  commonly  these  cases  have  been  allowed  to  advance  to  a  state 
of  hopelessness  or  radical  surgical  operations  have  been  inadvisably 
performed  with  unnecessary  personal  disfigurement  or  danger  as  the 
result.  Many  extrabuccal  affections  might  also  be  checked  in  their 
incipiency  if  dentists  who  have  opportunity  to  observe  them  during 
early  stages  fully  recognized  their  significance. 

The  discussion  of  a  field  of  practice  ^ith  hitherto  ill-defined  limi- 
tations, situated  like  the  hub  of  a  great  physiological  and  pathological 
wheel,  around  which  center  and  from  which  radiate  almost  limitless 
possibilities  for  the  reception  and  extension  of  disease,  has  required 
much  thought  in  the  determination  of  its  boundaries.  In  this  effort 
the  difficulty  of  conveying  a  true  idea  of  the  etiological  and  patho- 
logical importance  of  the  oral  region  in  relation  to  other  parts  and 
to  the  organism  as  a  whole  without  going  too  far  afield  in  the 
discussion  has  been  realized. 

Great  labor  has  been  expended  in  an  effort  to  present  the  subject 
with  sufficient  broadness  to  cover  all  affections  directly  and  indirectly 
related,  and  yet  to  confine  descriptive  matter  to  facts  that  are  essen- 
tial to  the  fulfilment  of  the  purpose  of  the  work. 

\Yidening  of  the  nares  by  separation  of  the  maxillse  for  the  correc- 
tion of  nasal  defects  and  the  control  of  pathological  influences  that 
may  affect  the  nose  and  associated  parts  through  the  mouth  is  fully 
illustrated  and  described,  because  such  work  is  properly  within  the 
scope  of  the  functions  of  the  oral  surgeon. 

The  operative  treatment  of  diseases  of  the  nose  and  throat  has 
been  omitted  because  this  lies  outside  of  the  province  of  oral  surgery. 


PREFACE  TO  THE  FIRST  EDITION  xi 

Although  partial  or  complete  stenosis  of  the  nares,  deflected  nasal 
septa,  diseases  of  the  nasal  accessory  sinuses,  adenoids  and  enlarged 
tonsils  and  pathological  results  attendant  upon  these  conditions  are 
commonly  associated  with  diseases  and  malformations  of  the  mouth, 
their  improvement  often  being  attendant  upon  the  correction  of  oral 
defects,  it  is  nevertheless  true  that  rhinologists  are  better  fitted  for 
the  local  operations  they  require,  and  ^vhene^'er  possible  should  be 
the  only  ones  to  attempt  them. 

In  like  manner  it  will  be  ob^^ous  to  all  thoughtful  readers  that 
operations  such  as  the  removal  of  the  Gasserian  ganglion  can  only 
be  safely  performed  by  surgeons  of  acknowledged  skill  and  long 
experience  in  brain  surgery,  and  extensive  resections  of  the  jaws, 
grave  operations  upon  the  tongue,  dissections  of  cervical  glands,  as 
well  as  many  less  extensive  operations  upon  the  eyes,  ears,  nose  and 
other  parts  that  may  be  and  often  are  associated  with  the  mouth  in 
disease,  can  best  be  performed  by  those  whose  practice  has  especially 
fitted  them  for  the  diagnosis  and  surgical  operative  treatment  of 
pathological  conditions  within  the  region  of  their  greatest  experience. 
Description  of  the  technic  of  all  such  operations,  with  sufficient  detail 
to  prepare  those  unfamiliar  with  them  for  their  proper  performance, 
would  be  impossible  in  a  work  of  this  character,  and  the  attempt 
would  be  unwarranted.  On  the  other  hand,  because  the  symptoms 
of  diseases  requiring  such  operative  treatment  are  so  frequently 
manifested  in  the  mouth,  familiarity  with  their  nature  and  the  indi- 
cations by  which  they  may  be  recognized  is  vitally  important  for 
all  who  treat  oral  diseases.  Again,  in  order  to  secure  the  best  results 
it  is  necessary  not  only  that  such  cases  be  carefully  diagnosticated, 
but  also  that  the  one  who  refers  them  should  have  at  least  an  intelli- 
gent idea  of  the  most  appropriate  methods  of  treatment.  It  has 
therefore  been  the  author's  purpose^to  include  all  important  patho- 
logical conditions  that  affect  or  are  influenced  by  the  buccal  cavity 
and  its  immediately  surrounding  parts;  to  deal  thoroughly  with  the 
etiology  and  symptoms  of  these  affections  and  to  describe  the  neces- 
sary operative  procedures  clearly  and  concisely  with  sufficient  detail 
to  give  a  thorough  understanding  of  the  most  approved  methods  of 
treatment,  the  risk  involved  and  the  probable  results. 

Mindful  of  the  great  advancement  of  dentistry,  particularly  in 
oral  hygiene  and  prophylaxis,  oral  bacteriology  and  pathology,  the 
treatment  of  buccal  diseases  and  the  study  of  their  underlying  devel- 
opmental principles;  cognizant  also  of  the  great  opportunity  for  the 


XII  PREFACE   TO   THE  FIRST  EDITION 

application  of  knowledge  of  general  diagnosis,  pathology  and  surgical 
treatment  in  this  field,  such  as  might  only  be  expected  of  those  whose 
experience  has  been  upon  the  broad  lines  of  more  general  medical 
practice;  with  keen  realization  of  the  imperative  necessity  for  exact 
and  specific  methods  of  diagnosis  when  other  parts  are  involved  in 
oral  disease,  the  author  has  long  hoped  to  provide  a  u'ork  for  con- 
sultation which  might  lead  to  a  more  direct  clinical  application  of  all 
these  opportunities. 

The  author  is  greatly  indebted  for  valuable  advice,  scientific  infor- 
mation, personal  letters  and  other  assistance  to  Dr.  Edward  C.  Kirk, 
of  Philadelphia;  Dr.  Eugene  S.  Talbot,  of  Chicago;  Dr.  O.  H.  Foerster, 
Dr.  Nelson  INI.  Black  and  Henry  D.  Goodwin,  of  IMilwaukee;  Dr.  Lee 
W.  Dean,  of  Iowa  City;  Dr.  Yida  A.  Latham,  of  Chicago;  Dr.  M.  H. 
Cryer,  of  Philadelphia;  Dr.  Albert  J.  Ochsner,  of  Chicago;  Dr.  Charles 
H.  Frazier,  of  Philadelphia;  Dr.  George  W.  Crile,  of  Cleveland;  Parke, 
Davis  &  Co.  and  Dr.  N.  S.  Ferry,  of  Detroit;  Dr.  Shepard  W.  Foster, 
of  Atlanta,  Ga.;  The  Journal  of  the  American  Medical  Association; 
The  S.  S.  "White  Dental  INIanufacturing  Company  and  many  other 
friends  and  confreres  in  this  and  other  countries  for  helpful  coopera- 
tion and  contributions  to  literature  which  have  been  freely  quoted. 

G.  V.  L  B. 


CONTENTS. 


CHAPTER  I. 

Anesthesia — Hemorrhage — Shock 17 

CHAPTER  II. 

Pathological  Dentition 59 

CHAPTER   III. 

Infectious  Diseases 82 

CHAPTER   IV. 

Diseases  of  the  Mucous  Membrane  of  the  Mouth 151 

CHAPTER  V. 

Diseases  of  the  Nervous  System  Affecting  the  Buccal  Region       .      .     192 

CHAPTER   VI. 
Diseases  of  Bone 318 

CHAPTER  VII. 
Diseases  of  the  Glands 407 

CHAPTER  VIII. 
Tumors 431 

CHAPTER  IX. 

Diseases  of  the  Maxill.\rt  Sinus 495 

(  xiii ) 


XIV  CONTENTS 

CHAPTER  X. 

Diseases,  Tumors  and  Malformations  of  the  Tongue        531 

CHAPTER  XI. 

Nasal  Deformities  and  Diseases  ijj  Relation  to  the  Maxilla  .     546 

CHAPTER  XII. 
Malformations,  Diseases  and  Injuries  of  the  Lips 573 

CHAPTER  XIII. 
Harelip,  Cleft  Palate  and  Defects  of  Speech         576 

CHAPTER  XIV. 

The  Treatment  of  Wounds  under  War  Conditions 667 

Selected  List  of  Examination  Papers 704 

Index 713 


SUEGEEY  OF  ORAL  DISEASES  AND 
MALFOMATIONS. 


CHAPTER  I. 

ANESTHESIA— HEMORRHAGE— SHOCK. 

ANESTHESIA. 

The  administration  of  anesthetics  for  oral  operations  presents  all 
the  dangers  incident  to  general  anesthesia  for  operations  in  other 
regions,  as  well  as  additional  factors  which  render  safe  continuous 
insensibility  to  pain  more  than  ordinarily  difficult  to  secure.  As  these 
are  of  primal  clinical  importance  in  oral  surgical  operations,  it  seems 
best  to  limit  the  consideration  of  the  general  subject  of  anesthesia  to 
its  essentially  practical  aspects,  without  attempting  to  include  details 
which  may  be  found  in  monographs  and  text-books  such  as  De  Ford's 
work  on  Anesthetics.^ 

The  term  anesthesia  literally  denotes  loss  of  sensation  of  touch,  but 
its  usual  application  is  accepted  as  meaning  the  state  of  profound 
unconsciousness  induced  by  anesthetics. 

Insensibility  to  pain  may  be  produced  with  or  without  simultaneous 
loss  of  common  sensation,  but  as  usually  applied  in  surgery  analgesia 
means  loss  of  ability  to  feel  pain  without  complete  unconsciousness. 
Anesthesia  may  be  local  or  general.     The  jnincipal  anesthetic  agents  are: 

Solutions  injected  into  the  tissues  to  produce  local  anesthesia. 

Freezing. 

Nitrous  oxide  gas. 

Xitrous  oxide  gas  and  oxygen. 

Nitrous  oxide  gas,  oxygen,  ether  sequence. 

Somnoform. 

Ethyl  chloride. 

Chloroform. 

A.  C.  E.  (alcohol,  chloroform,  and  ether)  mixture. 

Ether. 

Scopolamin,  morphin,  ether. 

Rectal  anesthesia. 

Spinal  anesthesia. 

Intravenous  anesthesia  by  ether  and  chloroform. 

1  Lectures  on  Anesthetics  in  Dentistry. 
2  (17) 


18  ANESTHESIA— HEMORRHAGE— SHOCK 

Local  Anesthetics. — Local  anesthetics,  consisting  of  various  com- 
binations of  cocain,  eucain,  and  other  drugs,  have  been  quite  generally 
used  in  minor  operations  for  many  years,  particularly  by  dentists 
in  the  extraction  of  teeth.  Sloughing  and  necrosis,  which  sometimes 
involve  the  bone  structures  extensively,  have  been  frequent  results 
of  this  practice.  In  at  least  one  case  within  the  author's  knowledge 
paralysis  and  serious  cerebral  s^Tnptoms  followed  the  use  of  cocain 
and  adrenalin  injected  with  a  high-pressure  syringe  for  the  extraction 
of  an  impacted  third  molar.  Failure  to  observe  proper  surgical  cleanli- 
ness, which  may  cause  bacterial  or  other  matter  to  be  forced  from  the 
oral  cavity  into  the  circulation,  and  drugs  which  may  act  as  emboli, 
have  caused  much  of  this  trouble.  With  careful  technic  and  discrimi- 
nate use  of  drugs,  local  anesthesia  has  an  important  place  in  oral  as 
well  as  other  operations.  It  is  valuable  not  only  when  entirely 
depended  upon  to  abolish  painful  sensation,  but  also  as  an  adjunct  to 
general  anesthesia  for  nerve  blocking  to  prevent  shock  and  to  reduce 
the  amount  of  the  general  anesthetic  required. 

Cocain. — Cocain,  an  alkaloid  extracted  from  coca  leaves,  is  widely 
and  successfully  used  by  application  to  mucous  membrane  surfaces, 
particularly  for  operations  on  the  eyes  and  nose.  It  also  forms  the 
basis  of  many  of  the  extensively  advertised  proprietary  local  anes- 
thetics. 

The  difficulty  of  obtaining  a  supply  of  novocain  under  war  conditions 
has  recently  caused  more  or  less  experimentation  in  the  clinical  appli- 
cation of  cocain  by  injection,  and  better  results  are  reported  with  the 
more  improved  modern  technic  than  was  formerly  obtained  by  old 
methods.  Various  combinations  of  cocain  with  adrenalin  have  given 
good  results  without  appreciable  toxic  effect. 

Nevertheless  its  high  degree  of  toxicity  cannot  be  denied.  Almost 
unlimited  clincial  evidence  points  to  the  danger  of  individual  suscepti- 
bility which  sometimes  renders  almost  infinitesimal  doses  very  danger- 
ous. Even  the  combination  of  cocain  with  adrenalin  or  suprarenin 
does  not  always  give  entire  freedom  from  toxic  effects.  The  possi- 
bility of  the  beginning  of  the  much-to-be-dreaded  cocain  habit  is  also 
a  serious  objection  to  its  use. 

Eucain. — Eucain  is  much  safer  than  cocain,  and  possesses  nearly  as 
well-marked  anesthetic  properties. 

Stovain  and  Novocain  (0.5  per  cent,  solution). — IMainoli^  strongly 
urges  a  wider  use  of  this  mode  of  anesthesia  in  major  as  well  as  minor 
operations.  He  has  had  no  local  difficulties,  e.  g.,  skin  sloughing,  but  he 
seldom  uses  a  stronger  solution  than  1  per  cent,  given  in  a  10  c.c.  s\Tinge. 
It  is  well  to  remember,  if  the  syringe  is  sterilized  in  an  alkaline  solution, 
that  stovain  becomes  chemically  altered  and  is  physiologically  inert. 
Lately  he  has  discarded  adrenalin,  as  he  claims  it  gives  no  real  advan- 

1  British  Med.  Jour.,  November  19,  1910,  quoted  from  Riforma  Medica. 


ANESTHESIA  19 

tage.  Novocain,  lie  holds,  lessens  the  smarting  which  stovain  some- 
times causes. 

Apothesin. — Apothesin  is  a  synthetic  anesthetic  now  being  brought 
forward  as  a  substitute  for  novocain.  It  is  claimed  to  l)e  fully  as 
potent  as,  and  also  less  toxic  than  the  various  similar  substances,  such 
as  stovain,  cocain,  novocain,  and  eucain.  Allen^  states  it  is  readily 
soluble  in  alcohol  and  very  soluble  in  water.  He  reports  in  detail 
ui)on  a  large  number  of  injections  made  upon  himself  for  experimental 
purposes  and  also  has  had  successful  clinical  experience.  It  is  sup- 
plied in  1  |-grain  tablets,  which  dissolved  in  60  minims  of  water  makes 
a  1  per  cent,  solution.  It  is  claimed  to  be  suitable  for  use  in  any  surgical 
procedure  which  requires  the  use  of  a  local  anesthetic.  The  solution 
generally  employed  is  5  per  cent,  to  3  per  cent.  Reports  from  900  to 
1000  operations  by  many  operators,  and  for  a  large  variety  of  opera- 
tions, seem  to  indicate  its  safety  and  efficiency,  both  of  which  time 
will  be  required  to  fully  determine. 

Quinine-urea  Hydrochloride. — The  advantages  claimed  for  quinine- 
urea  hydrochloride  as  a  local  anesthetic  are:  (1)  Any  operation 
ordinarily  done  under  cocain  can  be  done  with  quinine-urea.  (2)  The 
duration  of  anesthesia  with  0.5  to  1  per  cent,  solutions  is  longer  than 
when  cocain  is  used.  (3)  Solutions  of  this  strength  (1  per  cent.)  cause 
some  induration.  (4)  Union  may  be  a  little  delayed  by  a  fibrinous 
exudate  when  the  stronger  solutions  (1  per  cent,  or  over)  are  used.  (5) 
In  operations  about  the  anus  and  in  tonsillectomies  it  is  the  anesthetic 
of  choice,  as  it  has  a  hemostatic  effect  and  the  pain  of  dressings  is 
avoided. 

Its  advantages  over  cocain  are:  (1)  Its  absolute  safety.  (2)  The 
duration  of  anesthesia.     (3)  Its  hemostatic  eftect. 

H.  F.  Graham  tried  this  combination  in  17  cases.  A  1  per  cent, 
solution  was  generally  used  (made  from  the  2-grain  tablets  of  Parke, 
Davis  &  Co.),  and  the  solution  boiled  before  use.  As  a  result  of  his 
experience,  he  believes  it  is  a  perfectly  safe  local  anesthetic,  causing 
only  slight  local  irritation.  It  does  not  cause  tissue  destruction,  and 
if  it  interferes  with  healing  at  all,  does  so  only  to  a  slight  degree. 

Partial  Scopolamin  Anesthesia  for  Aged. — A  method  of  anesthesia 
for  the  aged,  advocated  by  J.  H.  Gleason,^  is  as  follows:  Some  six 
years  ago  he  conceived  the  idea  of  combining  partial  scopolamin  anes- 
thesia with  local  anesthesia,  using  0.1  per  cent,  of  cocain.  The  scopol- 
amin was  added  to  control  the  nervousness  and  excitement  usually 
complicating  operations  under  local  measures.  This  technic  proved 
so  successful  that  about  a  year  later,  opportunity  having  presented 
itself,  he  began  to  use  partial  scopolamin  anesthesia  combined  with  local 
sterile  water  infiltration  in  the  aged. 

1  New  Orleans  Med.  and  Surg.  Jour.,  March,  1917. 
«  New  York  Med.  Jour..  June  30,  1910. 


20  ANESTHESIA— HEMORRHAGE— SHOCK 

Infiltration  Anesthesia.— Schleich's formula  for  infiltration  anesthesia: 

Cocain  hydrochlorate 0.2 

Morphin  hydrochlorate 0.025 

Sodium  chloride 0.2 

Water  to  make 100.0 

Sterilize  and  then  add  two  drops  of  5  per  cent,  solution  of  carbolic 
acid. 

Infiltration  and  Conductive  Anesthesia  (Nerve-blocking). — Novocain 
is  a  synthetic  preparation  entirely  different  in  its  chemical  nature 
from  cocain.  Its  record  of  thousands  of  injections  in  persons  of  all 
ages,  under  many  different  conditions,  with  almost  no  serious  results 
at  present  entitles  it  to  first  rank  among  the  agents  for  inducing  both 
infiltration  and  conductive  anesthesia. 

According  to  Le  Borcq,  "If  the  toxicity  of  cocain  be  represented 
as  1,  then 

"The  toxicity  of  al^'pin  will  represent  1.25. 
"The  toxicity  of  nirvanin  will  represent  0.814. 
"The  toxicity  of  stovain  will  represent  0.625. 
"  The  toxicity  of  tropacocain  will  represent  0.500. 
"The  toxicity  of  novocain  ^vill  represent  0.490. 
"The  toxicity  of  beta-eucain  lactate  will  represent  0.414." 
Braun  recommends  the  use  of  solutions  for  this  purpose  varying 
from  0.25  per  cent,  to  2  per  cent,  novocain,  but  from  1  per  cent,  to  1.6 
per  cent,  solution  is  recommended  by  Fischer,  Seidel,  Blum  and  Thoma, 
and  approximately  these  percentages  are  generally  used  for  dental  and 
oral  operations. 

Fischer  advocates  a  novocain  solution  of  the  following  composition: 

Novocain 1  or  1.5  or  2.0 

Sodium  chloride 0.5 

Calcium  chloride 0 .  04 

Potassium  chloride 0.02 

Sterile  aqua  destillata 100.0 

Synthetic  suprarenin  (1  to  lOOj 0.002 

The  equipment  for  this  purpose  consists  of  a  sjTinge,  as  shown  in 
Fig.  1  with  both  long  and  short  needles,  and  trocar  needles,  as  shown 
in  Figs.  2  and  3;  a  glass  jar  for  preserving  the  s\Tinges  in  the  sterile 
alcohol  solution;  a  small  porcelain  dissolving  cup,  and  a  stock  flask 
for  the  Ringer  solution  (Fig.  4);  platinum  and  iridium  needles  are 
desirable  because  of  the  danger  of  breaking  which  steel  points  offer. 
Distilled  water  is  preferable  to  undistilled  boiled  water  because  of  its 
greater  purity.  A  convenient  apparatus  for  the  distillation  of  water 
makes  a  desirable  addition  to  this  armamentarium.  The  best  way  to 
make  a  syringe  sterile  is  to  boil  it. 

Technic  of  Infiltration  Anesthesia. — The  technic  of  Thoma,  of  Har- 
vard, includes  scrupulous  cleansing  preparation  of  the  mucous  mem- 


ANESTHESIA 


21 


brane  surface,  touching  the  point  of  entrance  with  the  solution  of  iodin 
and  aconite.     Then  with  the  s^Tinge  held  like  a  writing  pen  the  needle 


Fig.  1. — Fischer  injection  syringe. 


is  pushed — opening  directed  toward  the  bone — down  to  the  periosteum, 
and  thence  upward,  just  a  little  higher  than  the  apex  of  the  root.     The 


22 


ANESTHESIA— HEMORRHAGE— SHOCK 


injection  must  be  made  slowly  and  evenly,  and,  if  correct,  very  little 
force  is  needed.  In  this  manner,  deposit  of  1  to  1.5  c.c.  of  a  1.6  per 
cent,  solution  just  over  the  apex  of  the  root,  between  mucous  membrane 
and  bone.  The  tissue  should  not  turn  white  and  the  velum  is  hardly 
noticed,  because  the  deposit  of  the  solution  is  higher  than  the  mucous 
fold  of  the  cheek.  At  the  palatal  side,  insert  the  needle  nearer  the 
gingival  margin,  push  it  down  parallel  with  the  root  and  inject  0.25  c.c. 


Fig.  2. — Syringe  for  trocar. 


of  the  solution.  The  anesthesia  takes  place  in  from  five  to  eight  min- 
utes. Massage  of  the  part  will  help  quicken  the  process.  The  anes- 
thesia lasts  for  one  hour,  and  any  dental  or  surgical  operation  can  be 
performed  on  this  tooth. 

Braun  states  that  descriptions  of  the  method  of  anesthetizing  the 
inferior  alveolar  and  lingual  nerves  at  the  lingula  were  given  by  Halsted 
and  Raymond  (1885).     Efforts  were  then  made  by  dentists  to  block 


ANESTHESIA 


23 


the  inferior  alveolar  nerve  at  the  lingula  (Thiesing,  Krichelsdorf,  Dill 
and  Iluebner)  by  means  of  cocain-suprarenin  solution,  and  this  method 
has  now  become  one  of  the  common  procedures  of  the  dentist. 


Pig.  3. — Trocar  needles  with  telescoping  attachments.     (Fischer.) 

The  technic  of  the  operation,  according  to  Braun's  method  is  as 

follows: 

In  order  to  anesthetize  both  nerve  trunks,  proceed  in  this  manner: 
With  the  patient  in  a  sitting  posture  and  the  mouth  wide  open,  the 
operator  introduces  the  index  finger  of  the  left  hand  and  locates  the 
anterior  border  of  the  coronoid  process,  and  the  "trigonum  retro- 
molare"  (retromolar  triangle).  The  needle  is  directed  from  the  oppo- 
site canine  tooth  toward  the  retromolar  triangle  and  held  parallel 
to  the  biting  surface  of  the  lower  teeth.  The  needle  is  inserted  at 
the  above-mentioned  point  1  cm.  above  and  laterally  to  the  biting 


24 


A  NESTHESIA—HEMORRHA  GE—SHOCK 


surface  of  the  last  molar  tooth  into  the  "trigonum  retromolare." 
Immediately  under  the  thin  mucous  membrane  the  bone  should 
be  felt.  If  this  is  not  the  case,  the  point  of  the  needle  is  too  far  mesially, 
a  mistake  frequently  made  by  beginners.  The  needle  is  now  directed 
gradually  toward  the  median  line  until  the  internal  oblique  line 
is  felt. 

The  needle  finally  passes  along  the  imier  surface  of  the  lower  jaw  into 
the  deeper  parts.     It  must  now  be  further  inserted  to  a  depth  of  2 


Fig.   4. — Hermetically  sealed  glass  jar  for  preserving  syringes,  dissolving  cup,  and  pliers 
in  alcohol-glycerin  solution.     (Fischer.) 


to  2.5  cm.,  keeping  it  always  in  contact  with  the  bone.  On  the  whole 
path  described  by  the  needle  point,  beginning  immediately  under  the 
mucous  membrane,  where  the  lingual  nerve  lies,  5  c.c.  of  a  1  to  2  per 
cent,  novocain-suprarenin  solution  should  be  injected.  The  methods 
of  injection  are  illustrated  in  Figs.  5  to  10. 


ANESTHESIA 


25 


FISCHER  S   TABLES   FOR   INJECTING   LOCAL   ANESTHESIA. 


TKCHNIC    OF    INJECTION    EMPLOYED. 


Teeth 
I.   Upper. 
1.  Central 
incisors. 


2.  Lateral 
incisors. 


3.  Canines. 


4.  First 
biscuspids. 


5.  Second 
bicuspids. 


6.  First 
molars. 

7.  Second 
molars. 

8.  Third 
molars. 

II.  Lower. 

9.  Central 
incisors. 


10.  Lateral 
incisors. 


11.  Canines. 


12.  First     and 
second 
bicuspids 
and  first 
and  second 
molars. 


(o) 
Simple  cases. 


Needle  inserted  at  mid- 
dle of  root  of  lateral,  and 
directed  to  root  apex  of 
central. 


(&) 


Needle  inserted  at  mid- 
dle of  root  of  canine  and 
directed  to  root  apex  of 
lateral.  Palatally,  injec- 
tion at  lateral. 

Needle  inserted  at  root 
apex  of  canine,  where  solu- 
tion is  deposited.  Palat- 
ally, injection  at  canine. 

Needle  inserted  at  mid- 
dle of  root  of  canine,  and 
directed  to  root  apex  of  first 
bicuspid.  Or  injection  at 
maxillary  tuberosity. 

Needle  inserted  at  mid- 
dle of  root  of  first  bicuspid 
and  directed  to  root  of  sec- 
ond bicuspid.  Or  injection 
at  maxillary  tuberosity. 


Injection      at      maxillary 
tuberosity. 


Needle  inserted  at  root 
of  lateral  and  directed  to 
root  apex  of  central.  Lin- 
gually,  injection  at  central. 

Needle  inserted  at  mid- 
dle of  root  of  canine,  and 
directed  to  lateral.  Lin- 
gually    injection    at    lateral. 

Needle  inserted  in  reflec- 
tion of  mucous  membrane 
below  canine,  and  directed 
to  mental  fossa,  where  solu- 
tion is  deposited.  Lingually 
injection  at  canine,  first 
bicuspid,  or  mandibular 
anesthesia. 

Mandibular  anesthesia. 


In  cases  complicated  by  periostitis, 
parulis,  abscesses,  etc. 


Needle  in.serted  at  middle  of 
roots  of  canine  of  same,  and  central 
of  opposite  side,  whose  root  apices 
are  infiltrated  with  solution  palat- 
ally, injections  at  lateral  of  same, 
and  central  of  opposite  side.  Or 
conductive  anesthesia  at  infra- 
orbital foramen,  and  mucous  anes- 
thesia at  central  of  opposite  side, 
palatally. 

Needle  inserted  back  of  root 
apex  of  canine,  where  solution  is 
deposited;  same  procedure  at  root 
apex  of  central.  Palatally,  injec- 
tion at  lateral,  or  at  central  and 
canine. 

Conductive  anesthesia  at  infra- 
orbital foramen.  Palatally,  injec- 
tion at  canine,  or  first  bicuspid 
and  lateral. 

Injection  at  maxillary  tuber- 
osity. 


Injection    at    maxillary    tuber- 
osity. 


Needle  inserted  in  reflection  of 
mucous  membrane  below  canine 
and  directed  to  mental  fossa,  where 
solution  is  deposited. 

Needle  inserted  in  reflection  of 
mucous  membrane  below  canine, 
and  directed  to  mental  fossa,  where 
solution  is  deposited. 

Needle  inserted  in  reflection  of 
mucous  membrane  below  canine, 
and  directed  to  mental  fossa,  where 
solution  is  deposited.  Mandibular 
anesthesia. 


26 


ANESTHESIA— HEMORRHAGE— SHOCK 


Stern  recommends  an  injection  of  the  sphenomaxillary,  for  which 
purpose  he  uses  a  modification  of  the  Fischer  syringe  with  bayonet 


Fig.  5. — Illustration  of  the  direction  of  the  syringe  in  injtM-tinn  on  the  labial  side  for 
roots  of  the  anterior  teeth. 

attachment  and  needle  (see  Figs.  11  and  12)  and  claims  thereby  a  more 
complete  anesthetization,  \\hich  includes  with  greater  certainty  the 
pulps  of  the  bicuspid  teeth. 


Fig.  6. — Illustration  of  the  direction  of  the  syringe  for  injection  of  the  Ungual  aspects 
of  the  roots  of  the  anterior  teeth. 


Danger. — The  actual  danger,   \Aith  careful  technic,  is  practically 
nil,  but  cases  have  been  reported  in  which  unduly  prolonged,  appar- 


ANESTHESIA 


27 


ently  hypnotic  slumber,  evidences  of  slight  toxic  action,  and  distress 
due  to  injection  of  the  agent  into  the  muscles  instead  of  close  to  the 


Fig.  7. — Illustration  showing  the  direction  of  the  syringe  for  injection  on  the  palatal 
side  for  bicuspid  and  molar  roots. 

bone,  and  occasionally  local  disturbances  due  to  hemorrhages  have 
been  observed. 


Fig.  8. — Injection  at  the  infra-orbital  foramen. 

The  forcing  of  infection  from  septic  foci  at  the  apices  of,  or  other- 
wise in  connection  with  the  roots  of  the  teeth  is  always  a  serious  menace 
when  such  conditions  exist.     Stern^  calls  attention  to  this   danger, 


1  Dental  Cosmos,  January,  1916. 


28 


ANES  THESIA— HEMORRHAGE— SHOCK 


and  Fischer  has  also  given  the  matter  much  consideration  as  shown  by 
the  foregoing  partial  representation  of  his  chart  (page  25),  indicating  the 
difference  in  the  technic  of  injection  employed  in  simple  and  diseased 


Fig.  9. — Injection  at  the  mental  foramen  for  anesthesia  of  the  anterior  teeth. 

cases.     Doubtless  many  results  attributed  to  the  anesthetic  agent 
have  really  been  due  to  injudicious  extension  through  faulty  technic. 


Fig.   10. — Direction  of  syringe  for  injection  at  tlie  mandibular  foramen. 


General  Anesthetics.^For  general  anesthesia  the  oral  surgical  operator 
is  practically  limited  to  nitrous  oxide  and  oxygen,  somnoform,  ether, 
and  the  nitrous-oxide-oxygen-ether,   or  the  scopolamin,   or  hyocin- 


ANESTHESIA 


29 


mor[)hiii-ether  sequence,  as  nitrous  oxide  without  oxygen  is  not  capable 
of  sufficiently  extended  use,  and  the  safe  employment  of  ethyl  chloride 
is  too  limited. 

Rectal  anesthesia  is  objectionable  because  of  the  likelihood  of  irritation 
and  intestinal  disturbance  following  its  long  continuance. 

Spinal  anesthesia  is  not  applicable. 

Intravenous  anesthesia  by  ether  and  chloroform  has  been  recommended 
by  L.  Burkhardt/  who  uses  a  5  per  cent,  solution  of  ether  in  sterile 
salt  solution.  This  method  is  too  little  known  and  presents  too  many 
dangerous  possibilities  to  warrant  immediate  recognition. 


Fig.  11. — Stern's  modification  of 
the  Fischer  syringe  with  bayonet 
attachment  for  sphenopalatine  in- 
jection. 


Fig. 


12. — Illustration  of  Stern's  method  of 
sphenopalatine  injection. 


Chloroform. — Notwithstanding  the  fact  that  chloroform  has  long 
been  held  to  be  the  most  satisfactory  anesthetic  for  mouth  operations, 
the  author,  after  having  used  it  for  a  number  of  years,  unhesitatingly 
states  that,  except  in  the  extremely  rare  cases  where  other  anesthetics 
are  contra-indicated,  it  should  never  be  used  even  with  infants  and 
children.  By  careful  administration,  satisfactory  results  may  be 
obtained  by  the  use  of  ether,  with  less  immediate  and  postoperative 
danger  than  follows  chloroform.  One  patient,  a  young  woman,  aged 
about  twenty-two  years,  was  lost  five  days  after  operation,  after 
sufficient  recovery  to  have  enabled  her  to  return  home  if  desirable, 
as  a  result  of  acetonuria  and  fatty  degeneration  of  the  liver,  evidenced 


'  Miinchen.  med.  Wchnschr.,  November  16,  1909. 


30  ANESTHESIA— HEMORRHAGE— SHOCK 

by  almost  continuous  vomiting,  which  ended  in  black  \-omit,  delirium, 
coma,  and  death,  and  other  similar  cases  have  since  been  reported  by 
Bevan,  Guthrie,  Favil,  and  others.  These  have  convinced  the  author 
that  there  is  no  warrantable  excuse  for  the  continued  general  use  of  an 
agent  attended  by  the  immediate  mortality  due  to  chloroform,  and  the 
comparatively  high  though  seldom  recorded  postoperative  death-rate 
that  is  doubtless  even  greater  than  is  commonly  believed. 

Some  exception  must  be  made  when  chloroform  is  used  with  an 
apparatus  attached  to  an  oxygen  cylinder,  so  that  pure  oxygen  may  be 
forced  in  with  the  anesthetic.  In  this  way,  the  quantity  of  chloroform 
required  to  produce  insensibility  to  pain  is  greatly  reduced  and  the 
direct  effect  of  the  oxygen  undoubtedly  combats  the  dangerous  elements 
of  the  drug.  Unless  there  are  contra-indications  of  unusual  character, 
the  author,  however,  prefers  the  use  of  ether,  as  described  on  page  33. 

Nitrous  Oxide  Gas  and  Oxygen. — Nitrous  oxide  gas  undoubtedly 
is  the  safest  of  all  general  anesthetics.  Although  extensively  used 
for  a  long  time,  it  is  only  recently  that  a  full  appreciation  of  its  useful- 
ness has  developed,  because,  notwithstanding  its  simplicity,  this  agent 
requires  great  skill  in  administration  to  obtain  the  best  result.  Its 
mortality  record  during  the  years  of  its  general  use  is  much  better 
than  that  of  any  other  general  anesthetic,  and  some  of  the  deaths 
attributed  to  nitrous  oxide  anesthesia  are  undoubtedly  due  to  other 
causes.  Any  operator  can  administer  gas  to  the  point  of  complete 
insensibility  with  the  usual  appearance  of  temporary  asphyxiation 
and  in  short  minor  operations  by  rapid  work  accomplish  fairly  good 
results.  But  its  safe  administration  in  combination  with  oxygen, 
continued  for  an  hour  or  longer,  with  the  patient  in  a  state  of  complete 
muscular  relaxation  or  of  analgesia,  more  or  less  conscious  of  what  is 
being  done  but  without  painful  sensation,  requires  skill,  which  must  be 
supplemented  by  natural  talent  and  adaptability  upon  the  part  of  the 
administrator,  and  even  then  this  skill  can  only  be  acquired  by  long 
experience,  in  sufficient  degree  to  insure  successful  accomplishment. 
Such  a  result,  however,  is  well  worth  painstaking  effort  to  secure, 
because  freedom  from  nausea  and  other  unpleasant  symptoms  at  the 
time  of  operation,  and  quick  recovery,  are,  in  many  cases  and  under 
a  large  variety  of  pathological  conditions,  of  priceless  value. 

That  the  prolonged  administrations  of  nitrous  oxide  gas  is  not  un- 
attended by  danger  is  shown  by  the  following  table  of  deaths:' 

Case  1. — Teter:  "Shock  and  Primary  Cardiac  Failure,"  Jour.  Am. 
Med.  Assn.,  August  7,  1909,  p.  448. 

Case  2. — Crile:  "Myocarditis  Six  Hours  after  Operation,"  Southern 
Med.  Jour.,  January,  1910,  p.  29. 

Case  3. — Lydston:  "Anesthetic,"  Med.  Record,  November  12,  1910, 
p.  866. 

1  Miller,  Alfred  H.:  Dental  Cosmos,  June,  1915. 


ANESTHESIA  31 

Case  4. — Allen:  "Uremia,"  Boston  Med.  and  Surg.  Jour.,  October 
19,  1911,  p.  589. 

Case  5. — Allen:  "No  Details,"  Jour.  Am.  Med.  Assn.,  February  10, 
1912,  p.  396. 

Case  6.— Allen:  "No  Details"  (ibid.). 

Case  7. — Gatch:  "Hyperthyroidism,"  Jour.  Am.  Med.  Assn., 
November  11,  1911,  p.  1593. 

Case  8. — Gatch:  "Pericardial  Effusion"  (ibid.). 

Case  9. — Gatch:  "Lymphatic  Diathesis"  (ibid.). 

Case  10. — Olow:  "  Diseased  Heart  and  Arteries,"  Beitrdge  kiln.  Chir., 
December,  1911. 

Case  11. — Boys:  "Anesthetic,"  Surg.,  Gynec.  and  Obst.,  April,  1912, 
p.  388. 

Case  12. — Miller:  "Suffocation  from  Inspired  Vomitus,"  Jour.  Am. 
Med.  Assn.,  November  23,  1912,  p.  1847. 

Case  13. — Flagg:  "Anesthetic,"  Neiv  York  Jour.  Med.,  November, 
1912. 

Case  14. — Teter:  "Impure  Gas,"  Jour.  Am.  Med.  Assn.,  November 
23,  1912,  p.  1849. 

Case  15. — ^Teter:  "Impure  Gas"  (ibid.). 

Case  16. — Salzer:  "Anesthetic,"  Jour.  Am.  Med.  Assn.,  November 
23,  1912,  p.  1872. 

Case  17. — Collins:  "Impure  Gas,"  Jour.  Am.  Med.  Assn.,  November 
23,  1912,  p.  1862. 

Case  18. — Buchanan:  "Anesthetic,"  Jour.  Am.  Med.  Assn.,  Novem- 
ber 23,  1912,  p.  1860. 

"A.  H.  Miller^  has  collected  references  to  18  deaths.  Teter  knows 
of  26  fatalities.  Rovsing  was  able  to  get  track  of  13  deaths,  several  of 
which  had  been  suppressed.  Gwathmey  knows  of  20  to  40  unreported 
deaths." 

Practically  all  anesthetists  state  most  positively  that  death  occurs 
only  from  asphyxia,  and  if  the  anesthetist  watches  the  color  and  pushes 
the  oxygen,  death  cannot  occur.  In  none  of  the  cases  detailed  was 
death  the  result  in  any  way  whatever  of  asphyxia,  but  in  all  occurred 
without  warning. 

In  Columbus,  O.,  there  have  been  12  or  13  deaths  when  given  for 
1200  to  1300  major  operations. 

Nitrous  Oxide-oxygen-ether  Sequence. — The  administration  of  nitrous 
oxide  gas,  preliminary  to  ether  anesthesia,  is  at  present  quite  generally 
employed  in  hospitals  throughout  the  United  States.  Many  ingenious 
devices,  such  as  the  inhalers  of  Teter,  of  Cleveland;  Dr.  Willis  M. 
Gatch,  of  Baltimore;  A.  E.  Clark,  of  Chicago;  the  S.  S.  White  Co.,  of 
Philadelphia,  and  others  have  been  designed  to  regulate  the  respective 
quantities  of  nitrous  oxide,  oxygen,  and  air  employed,  and  the  addition 

1  Baldwin:  Practical  Medicine  Series,  ii,  25,  and  Medical  Record,  July  29,  1916. 


32  ANESTHESIA— HEMORRHAGE— SHOCK 

of  chloroform  or  ether  in  such  manner  as  to  produce  safe  and  gradual 
transition  to  the  agent  (whether  chloroform  or  ether)  that  is  to  be 
depended  upon  for  continued  general  anesthesia  during  the  operation. 
Thus  one  of  the  principal  objections  to  the  use  of  nitrous  oxide  as  a  first 
step  to  ether  is  avoided,  viz.,  that  during  the  preliminary  stage,  patients 
quite  frequently  recovered  sufficiently  to  overcome  the  intended  benefit 
of  the  quick  induction  through  the  nitrous  oxide  of  the  anesthetic  state. 
The  apparatus  which  also  permits  reinhalation  it  is  claimed  gives  much 
benefit. 

Somnoform. — Somnoform  is  safer  than  ethyl  chloride  or  ethyl  bro- 
mide, which  with  methyl  chloride  are  its  component  parts.  Of  all  the 
general  anesthetics,  it  is  undoubtedly  the  easiest  to  administer  and 
most  rapid  in  action.  According  to  De  Ford,  "the  time  required  being 
from  fifteen  to  thirty  seconds,  with  a  period  of  available  anesthesia 
from  sixty  to  three  hundred  seconds."  (The  death-rate  of  ethyl 
chloride  is  estimated  to  be  1  in  about  5000  administrations.)  Its  chief 
recommendation  for  safety,  however,  lies  in  this,  that  it  has  been 
generally  and  carelessly  administered,  yet  with  almost  perfect  success, 
in  clinical  exliibitions  and  otherwise,  by  absolutely  untrained  people, 
to  individuals  who  have  had  no  sort  of  preparation  or  preliminary 
physical  examination.  Had  it  not  been  a  more  than  ordinarily  safe 
agent,  the  death-rate  would  long  ago  have  become  a  serious  matter. 
For  very  brief  operations  its  value  is  undoubted.  The  limited  knowl- 
edge of  its  effect  in  continued  use  or  repeated  administration,  however, 
seems  to  limit  it  to  operations  that  can  be  quickly  performed  or  to 
administration  as  a  preliminary  to  ether  anesthesia.  For  children 
under  age  when  nitrous  oxide  can  be  readily  and  satisfactorily  given, 
and  when  the  terror  incited  by  ether  administration  is  a  serious  danger 
in  unduly  exciting  brain  cells  which  may  involve  the  vital  centers,  its 
use  is  undoubtedly  advisable.  Except  in  these  cases  the  combination 
of  nitrous  oxide  and  oxygen,  which  can,  with  reasonable  safety,  be 
continued  for  an  alnxost  indefinite  period,  seems  to  be  much  more 
satisfactory. 

The  Desirable  Conditions  for  Anesthesia  for  Mouth  Operations. — 
With  the  mouth  wide  open  and  the  operative  field  occupied  by  the 
hands  of  the  operator,  comparatively  little  opportunity  is  given  to 
prevent  the  inhalation  of  air.  Thus  it  is  advisable  to  give  the  agent 
in  concentrated  form  through  such  airways  as  are  available  and  with 
the  apparatus  out  of  the  way  of  the  operator.  For  this  purpose  a 
rubber  tube  or  tubes  may  be  passed  through  one  or  both  of  the  nares 
back  into  the  pharynx,  or  the  agent  may  be  given  by  the  mouth  through 
a  tube,  hollow  mouth  gag,  or  other  similar  device.  In  this  way  at  least 
some  anesthetic  may  be  continuously  administered  while  the  operation 
is  in  progress.  Blowing  chloroform  or  even  ether  in  this  manner,  as  with 
the  Yunker  and  similar  apparatus,  so  that  condensation  may  force  the 
anesthetic  into  the  pharynx  and  thus  lead  to  its  being  swallowed  or 


ANESTHESIA 


33 


inhaled  in  crude  form,  may  si'Piitly  increase  its  irritating  properties  and 
even  endanger  the  Ufe  of  the  patient.  To  avoid  this,  the  author  recom- 
mends the  use  of  heated  anesthetics,  given  by  the  Gwathmey  (Figs.  13 


Fig.  13. — Gwathmey's  vapor  inhaler:  a,  a,  bottles  arranged  for  chloroform  or  ether, 
and  hot-water  bottle  through  which  these  agents  are  blown  before  passing  into  the 
administration  tube.  The  proportions  of  air  and  anesthetic  agent  are  regulated  by  turn- 
ing the  key  at  the  top  of  the  apparatus;  b,  hollow  inhaler,  with  holes  at  the  side  to  allow 
the  vapor  to  pass  under  the  mask  covered  with  gauze;  c,  tube  through  which  the  vaporized 
anesthetic  agent  is  blown  into  the  mouth  or  nose.  These  are  attached  to  the  apparatus 
by  rubber  tubing  and  air  is  blown  in  by  the  use  of  rubber  bulbs  or  foot  bellows. 


Fig.  14. 


-Rubber  face  mask  placed  over  the  inhaler  to  prevent  the  escape  of  the  vapor 
during  preliminary  administration. 


and  14)  or  some  similar  apparatus.  By  this  method  ether  which  has 
become  vaporized  by  heat  is  blown  through  the  tube  in  such  manner 
that  there  will  be  a  definite  proportion  of  air  with  it.  The  increased 
efficiency  of  heated,  vaporized  ether  makes  a  sufficiently  steady  anes- 
3 


34  ANESTHESIA— HEMORRHAGE—SHOCK 

thesia  possible  with  a  much  smaller  proportion  of  ether.  Thus  the 
danger  is  reduced  and  the  likelihood  of  postoperative  vomiting  mini- 
mized. The  latter  almost  invariably  means  infection  in  mouth  opera- 
tions and  in  cleft-palate  cases,  particularly  after  staphylorrhaphy,  for 
the  strain  thus  affecting  the  freshly  united  soft-palate  tissue  predisposes 
to  failure,  and  must  be  avoided  if  possible.  Too  profound  anesthesia, 
with  all  reflexes  abolished,  should  be  guarded  against  when  profuse 
hemorrhage  is  likely,  even  though  it  may  only  be  momentary,  as  blood  is 
apt  to  be  inspired  in  spite  of  every  precaution,  except  when  the  pharynx 
is  packed,  and  this  is  inadmissible  for  many  operations.  With  care 
and  skilful  administration,  the  patient  can  be  kept  completely  insensible 
to  pain  and  sufficiently  quiet  for  the  steady  progress  of  the  operation, 
and  yet  not  so  deeply  under  the  anesthetic  as  to  abolish  reflex  action 
entirely,  which,  even  though  limited,  is  a  very  important  safeguard. 
The  ideal  condition  for  anesthesia  in  this  region  is  administration  lasting 
the  shortest  possible  time  consistent  with  the  rapid,  thorough  perform- 
ance of  the  procedure.  This  implies  skilful  operation,  with  safe,  con- 
tinued, steadily  maintained  insensibility  to  pain,  without  loss  of  mus- 
cular and  nervous  activity  sufficient  to  cause  inspiration  of  blood,  and 
prevent  prompt  recovery,  with  freedom  from  postoperative  nausea  and 
other  ill  effects. 

A  h;sT5odermic  injection  of  |  gr.  of  morphin  and  yytt  gr-  of  afro  pin, 
one-half  hour  before  operation,  reduces  the  time  taken  for  induction 
of  anesthesia,  and  therefore  lessens  the  amount  of  the  anesthetic  re- 
quired, thus  diminishing  the  danger  of  the  early  stages  of  anesthesia 
and,  in  a  considerable  measure,  also  the  tendency  to  shock.  The 
atropin  diminishes  secretion  and  thus  lends  important  aid  to  both 
anesthetic  and  operative  conditions  in  the  buccal  and  pharyngeal 
cavities.  One-eighth  to  one-quarter  grain  of  morphin  injected  after 
the  operation  serves  to  bring  about  a  more  quiet,  restful  recovery, 
with  valuable  abatement  of  the  unpleasant  s^nnptoms  following  pro- 
longed anesthesia. 

The  essence  of  orange  administered  with  the  ether  at  the  beginning 
of  the  anesthesia  is  sometimes  beneficial  when  the  patients  particularly 
dread  the  smell  of  ether. 

Scopolamin-morphin  or  hyoscin-morphin  administered  hypodermic- 
ally  to  bring  about  sleep,  though  insufficient  for  the  performance  of  a 
major  operation  without  the  administration  of  an  additional  anes- 
thetic, reduces  the  required  amount  of  ether  or  other  similar  agent  to 
the  minimum.  It  has  been  frequently  recommended  by  many  writers, 
and  is  useful  where  more  than  ordinary  apprehension  of  danger  from 
ether  exists.  Its  injudicious  use  has  in  some  instances  caused  death 
through  retardation  of  the  action  of  the  heart  beyond  the  point  of 
control ;  and  until  such  time  as  experience  shall  have  defined  the  limita- 
tions of  this  combination  of  drugs,  prudence  would  indicate  that  its 
employment  be  regarded  as  merely  substituting  one  form  of  danger  for 


ANESTHESIA  35 

another.  H.  C.  WoocP  reports  1988  eases  and  23  deaths,  9  of  whieh  he 
believes  sliould  justifiably  be  attributed  to  the  anesthetic,  leaving 
the  record  of  1  death  in  221  anesthesias.  He  states:  "In  view  of  the 
fact  that  this  combination  for  the  production  of  anesthesia  is  scien- 
tifically irrational,  and  has  yielded  a  mortality  of  4  per  1000,  and  in 
G9  per  cent,  of  the  cases  the  anesthesia  has  been  unsatisfactory, 
.  .  .  it  must  be  either  a  very  bold  or  very  careless  surgeon  who  will 
persist  in  its  use." 

Collins,  ^^■ho  has  had  an  experience  of  1120  cases  in  which  scopolamin- 
morphin  was  given  preliminary  to  general  anesthesia,  gives  the  follow- 
ing description  of  its  use : 

"Tablets  are  obtained  containing  a  combination  of  scopolamin  y^-q 
gr.,  and  morphin  |  gr.,  and  the  solution  is  made  just  before  it  is  admin- 
istered hypodermically,  which  is  done  one  and  one-half  hours  before 
operation.  Relatives  or  friends  are  not  allowed  to  see  the  patient 
after  the  hj^odermic  has  been  given. 

"The  patient  is  not  to  be  talked  to  and  aroused.  All  necessary  man- 
ipulations and  handling  of  the  patient  are  completed  before  the  hypo- 
dermic is  administered.  The  room  is  darkened  and  everything  kept 
quiet,  and  he  falls  into  a  tranquil  slumber.  About  twenty  minutes 
before  operation  a  layer  of  damp  cotton  is  placed  over  the  eyes  and  the 
patient  is  taken  to  the  operating  room  and  placed  on  the  table.  The 
preliminary  cleansing  of  the  skin  is  gently  done  while  the  general 
anesthetic  is  being  administered.  The  preparation  and  anestheti- 
zation are  usually  completed  about  the  same  time,  and  the  operation 
proceeds. 

"  The  preliminary  injection  is  given  to  all  patients  from  eight  years 
up.  If  an  elderly  patient  is  strong  enough  to  undergo  an  operation, 
he  is  strong  enough  to  have  the  beneficial  effects  of  the  combination, 
and  it  has  not  been  withheld  on  account  of  age.  Children  are  more  apt 
to  be  nervous  and  apprehensive  than  adults;  therefore  the  preliminary 
is  given  to  all  children  of  eight  years  and  older. 

"About  thirty  minutes  after  the  hypodermic  the  patient  becomes 
drowsy,  and  all  apprehension  and  fear  regarding  the  operation  are 
gone.  The  transition  from  a  partial  sleep  to  complete  anesthesia  is 
not  sudden,  as  from  complete  wakefulness,  and  is  easily  accomplished. 
After  the  operation  he  usually  sleeps  from  three  to  five  hours,  and  may 
partially  awake  and  go  to  sleep  again  several  times  before  becoming 
completely  awake.  The  sleep  saves  him  from  the  smarting  pain  of  the 
recently  incised  tissues.  There  is  much  less  postoperative  vomiting, 
most  patients  having  practically  none.  The  secretion  of  mucus  is 
markedly  checked  and  in  most  cases  is  completely  stopped.  This 
prevents  aspiration.  "^ 

1  Jour.  Am.  Med.  Assn.,  December,  1906. 

2  Ibid..  March  26,  1910. 


36  ANESTHESIA— HEMORRHAGE— SHOCK 

Endotracheal  Anesthesia. — Endotracheal  as  administered  with  the 
Janeway  apparatus  gives  perfect  relaxation  with  less  anesthesia  than 
with  inhalation,  and  its  convenience  for  operations  when  surgeon  and 
anesthetist  occupy  the  same  field  is  also  emphasized.  The  method  is 
apparently  passing  the  trial  stage,  but  until  it  is  more  generally  adopted, 
there  seems  no  good  reason  why  it  should  supplant  other  well-estab- 
lished and  satisfactory  methods  of  anesthetic  administration  except 
in  selected  cases. ^ 

Oil-Ether  Colonic  Anesthesia. — J.  T.  Gwathmey^  claims  the  following 
advantages  for  this  method  of  anesthesia. 

(1)  The  apprehension  and  fear  caused  by  a  mask  is  avoided;  (2)  no 
expensive  apparatus  required;  (3)  after-effects  reduced  to  a  minimum; 
(4)  a  more  complete  relaxation  than  with  any  other  method;  (5)  limits 
of  safety  are  w"idely  extended  compared  with  other  methods;  and  (6) 
a  more  even  plane  of  anesthesia  is  automatically  maintained  than 
possible  by  any  inhalation  method — unless  administered  by  a  skilled 
anesthetist  using  a  perfected  apparatus. 

The  bowels  should  be  cleared  by  castor  oil  and  by  irrigation.  One 
hour  before  operation  a  mixture  of  2  to  4  drams  of  ether  in  which  is 
dissolved  5  to  10  grains  of  chloretone  and  2  to  4  drams  of  olive  oil,  is 
injected  into  the  rectum,  or  a  suppository  containing  5  to  10  grains 
of  the  chloretone  is  inserted.  Half  an  hour  before  the  operation  a 
hypodermic  injection  is  given  of  |  to  j  grain  of  morphin  sulphate  and 
j^Q  grain  of  atropin  sulphate.  About  fifteen  minutes  before  the  opera- 
tion the  patient  should  be  laid  on  the  left  side  in  a  modified  Sims  posi- 
tion and  a  mixture  of  25  parts  olive  oil  and  75  parts  ether  passed  into 
the  rectum  gradually,  through  the  small  tube  to  which  the  funnel  and 
clamp  have  been  fitted.  One  minute  should  be  allowed  for  the  intro- 
duction of  each  ounce  of  the  mixture. 

For  children  a  mixture  containing  50  to  65  per  cent,  of  ether  is 
sufficiently  strong.  One  ounce  of  the  mixture  is  required  for  each  20 
pounds  weight. 

Good  care  should  be  taken  to  keep  respiratory  conditions  free. 

At  the  conclusion  of  the  operation  the  clamp  on  the  rectal  tube  is 
released,  and  the  end  lowered  so  the  residual  mixture  is  siphoned  off. 
The  Lockwood  tube  is  inserted  about  6  inches  alongside  the  rectal  tube. 
About  a  gallon  of  cold  soapy  water  is  then  introduced  through  the 
funnel,  being  siphoned  oft"  by  the  Lockw*ood  tube.  Toward  the  end 
of  this  process  the  colon  is  massaged  gently  from  right  to  left,  thus 
expelling  any  liquid  which  may  be  left.  The  Lockwood  tube  is  then 
removed;  from  1  to  2  pints  of  cold  water  (tap  water)  is  introduced 
through  the  rectal  tube  and  the  tube  withdrawn. 


'  Vedin,  A.:  New  York   Med.   Jour.,   July  29,    1916.     Ochsner:  Practical   Medicine, 
Series  11,  1917. 

2  Lancet,  December  20,  1913. 


ANESTHESIA  37 

W.  M.  Johnson/  with  an  experience  of  50  cases  with  no  untoward 
effects,  recommends  the  following  prescription: 

Paraldehyde 3ij-iij 

Olive  oil 5ij 

Ether Biij-v 

He  gives  castor  oil  at  2  p.m.  the  day  preceding,  and  the  same  night 
(after  oil  has  acted)  colon  irrigation.  In  the  morning  one  or  two  colon 
irrigations  are  given  until  the  water  returns  clear.  Two  hours  before 
operation  5  to  15  grains  of  chloretone  per  os. 

A.  D.  Bevan-  reports  results  of  his  study  of  anesthesia  which  would 
cover  fully  the  entire  surgical  field  to  determine  which  would  be  the 
safest,  most  efficient,  most  satisfactory,  to  both  patient  and  surgeon, 
simplest  and  least  complicated.  He  desired  also  to  find  anesthetics 
which  could  be  adopted  and  employed  by  medical  men  generally. 
From  this  stand-point  the  following  have  been  analyzed: 

Cloroform  by  open  drop  method;  ether  by  open  drop  method;  nitrous 
oxide  gas;  scopolamin  and  morphin-;  spinal  anesthesia;  blocking;  infil- 
tration; intravenous;  general  and  local;  intrarectal;  intratracheal;  intra- 
pharyngeal;  mixtures;  sequences;  anoci-association. 

In  each  instance  these  agents  and  methods  have  been  analyzed  from 
the  stand-point  of: 

Safety;  comfort;  efficiency;  control;  simplicity  and  general  adapta- 
bility; after-effects  on  blood  and  tissues  and  viscera;  complications, 
vomiting,  etc. ;  paresis  of  bladder  and  bowels ;  effects  on  immunity  to 
pus  organisms,  pneumococcus,  etc. 

The  final  results  of  his  analysis  are  as  follows: 

1.  Drop  ether  should  be  today  chosen  as  the  standard  general  anes- 
thetic when  a  prolonged  anesthesia  is  desired  with  relaxation  and 
unconsciousness. 

2.  Gas  should  be  chosen  in  short  anesthesias  in  which  unconscious- 
ness is  desired,  and  in  special  cases,  e.  g.,  kidney  insufficiency. 

3.  Intrapharyngeal  ether  should  be  chosen  in  mouth  and  jaw  cases 
when  it  is  desirable  to  remove  the  anesthetist  and  the  apparatus  out 
of  the  operative  field. 

4.  Local  infiltration  anesthesia  should  be  chosen  when  the  surgeon 
has  the  full  co5peration  of  the  patient  and  when  the  field  can  be  com- 
pletely infiltrated  and  anesthetized  by  a  safe  amount  of  novocain  and 
epinephrin. 

These  simple  and  safe  methods  can  be  made  to  cover  all  surgical 
cases.  This  places  anesthesia  on  a  very  unpretentious,  simple  basis, 
but  here  as  in  most  fields  of  surgery  we  finally  learn  that  simplicity  is 
near  to  truth. 

1  Practical  Medicine,  Series  11,  1917.  Ochsner  (editor):  from  Vermont  Medica 
Monthly,  August,  1916. 

2  Jour.  Am.  Med.  Assn.,  October  23,  1915. 


38  ANESTHESIA— HEMORRHAGE— SHOCK 

After  performing  operations  upon  dogs  that  had  been  given  preHm- 
inary  injections  of  chloretone  at  the  Parke,  Davis  &  Co.  laboratories, 
and  observing  the  growing  tendency  to  recognize  the  vakie  of  morphin, 
scopolamin  and  morphin,  and  simihir  preparatory  drugs,  the  author 
beheves  that  future  advances  will  undoubtedly  be  in  the  direction  of 
greater  use  of  these  and  similar  preparations. 

In  this  connection  Dr.  George  V.  Crile,  of  Cleveland,  gives  the 
f ollow'ing  description  of  anoci-association,  a  word  he  has  coined : 

"The  difference  between  anesthesia  and  anoci-association  is  that, 
although  inhalation  anesthesia  confers  the  beneficent  loss  of  conscious- 
ness and  freedom  from  pain,  it  does  not  prevent  the  nerve  impulses 
from  reaching  and  influencing  the  brain,  and  hence  does  not  prevent 
surgical  shock  nor  the  train  of  later  nervous  impairments  so  well 
described  by  Mumford.  Anoci-association  is  accomplished  by  a  com- 
bination of  special  management  of  patients  (applied  psychology), 
morphin,  inhalation  anesthesia,  and  local  anesthesia. 

"In  operations  under  inhalation  anesthesia  the  nerve  impulses  from 
the  trauma  reach  every  part  of  the  brain — the  cerebrum  that  is  appar- 
ently anesthetized  as  well  as  the  medulla  that  is  known  to  remain  awake 
—the  proof  being  the  physiological  exhaustion  of  and  the  pathological 
change  in  the  nerve  cells. 

"But  if  the  nerve  paths  connecting  the  field  of  operation  and  the 
brain  be  blocked,  then  there  is  no  discharge  of  nervous  energy  from  the 
trauma,  and  consequently  no  exhaustion,  however  severe  or  prolonged 
the  operation." 

Many  authorities  do  not  hold  with  Crile  in  these  conclusions. 
Nevertheless,  there  can  be  no  question  as  to  the  result  of  their  applica- 
tion when  applied  to  modify  the  ill  effects  of  anesthetic  administration. 

HEMORRHAGE. 

Hemorrhage  denotes  the  escape  from  the  bloodvessels  of  all  the 
constitutents  of  the  blood.  The  recognized  forms  are:  Arterial, 
venous,  capillary,  mixed,  hemorrhage  per  diapedism,  i.  e.,  diapedesis 
and  extravasation  through  intact  vessels;  and  hemorrhage  per  rhexin, 
i.  e.,  by  actual  rupture  of  the  vessel. 

Etiology. — Hemorrhage  may  be  due  to  trauma  or  diseases  of  the 
bloodvessels,  or  it  may  result  from  neuropathic  condition  or  the  hemor- 
rhagic diathesis  (hemophilia). 

Classification. — The  principal  forms  of  hemorrhage  are  as  follows: 
Epistaxis,  nosebleed;  hemoptysis,  hemorrhage  of  the  lungs;  hematemesis, 
hemorrhage  from  the  stomach;  gastrorrhagia,  hemorrhage  from  the 
stomach  due  to  lesion;  enterorrhagla,  hemorrhage  from  the  bowels; 
metrorrhagia,  uterine  hemorrhage  at  other  than  menstrual  periods; 
menorrhagia,  immoderate  hemorrhage  at  the  menses;  ecchymosis, 
hemorrhage  infiltration  beneath  the  skin  or  mucous  membrane;  hemor- 


HEMORRHAGE  39 

rhagic  infarcts,  infiltration  of  blood  involving  localized  portions  of  a 
tissue  or  organ;  and  hematoiua,  blood  tumor. 

From  a  surgical  point  of  view,  hemorrhages  are  chiefly  divided 
into  (1)  primary,  hnmediately  following  division  of  the  vessels;  (2) 
reactionary,  when  the  clot  first  formed  is  dislodged  by  force  of  circu- 
lation in  recovery,  imperfect  ligatures,  or  other  causes  during  the  first 
few  hours  after  operation  or  injury;  (.3)  secondary  hemorrhage,  from 
sloughing  of  the  vessels  or  too  early  absorption  of  ligatures  several 
days  after  operation. 

Symptoms. — The  symptoms  of  hemorrhage  are  local  and  general. 

Local  Symptoms. — In  the  case  of  the  larger  arteries  the  local  symp- 
toms are  recognized  by  bright  red  blood  appearing  in  jets;  in  the  case  of 
veins  the  blood  flows  steadily  and  is  dark,  and  in  the  case  of  capillaries 
it  oozes.     In  ordinary  wounds  there  is  a  combination  of  the  three. 

General  Symptoms. — These  are  exceedingly  important,  because  the 
flow  of  blood  may  be  internal  or  at  least  concealed  from  external  obser- 
vation. They  are  recognized  by  rapid  pulse,  which  becomes  shallow 
and  irregular,  and  finally  so  slow  and  faint  as  to  be  almost  impercept- 
ible. The  face  is  pale  and  the  skin  moist  and  clammy,  with  cold  per- 
spiration. With  continued  profuse  flow  of  blood  unchecked,  respira- 
tion becomes  short  and  noticeably  difficult.  Roaring  in  the  ears,  light 
flashes  before  the  eyes,  fainting,  and  finally  syncope  ensues,  which 
sometimes  brings  such  a  weakened  action  of  the  heart  that  hemorrhage 
ceases  sufficiently  to  admit  of  recovery.  When  this  does  not  occur, 
dyspnea,  cessation  of  the  action  of  the  heart,  and  death  may  result. 

Treatment. — The  various  methods  commonly  used  in  arresting  hem- 
orrhage are  as  follows:  Ligation,  tying  of  the  ligature;  forcipressure, 
grasping  the  vessel  with  a  forceps;  torsion,  by  twisting  the  vessel  with 
forceps;  acupressure,  the  passing  of  a  needle  under  the  vessel,  bringing 
the  ends  above  the  tissues  upon  each  side,  and  ligating  in  the  form  of  a 
figure  8;  tourniquet,  passing  a  cord  or  bandage  of  sufficient  strength 
around  the  parts  and  twisting  until  compression  checks  the  flow  of 
blood ;  Esmarch  bandage,  a  rubber  bandage  wrapped  about  the  part  to 
make  compression  for  temporary  purposes,  as  for  amputation  of  an 
extremity;  styptics,  drugs  used  to  promote  contraction  of  the  vessels  or 
coagulation  of  the  blood;  constitutional  treatment,  frequently  required 
to  bring  the  blood  into  normal  condition,  when  as  a  result  of  disease 
or  predisposition  its  coagulative  properties  are  insufficient  and  the 
tendency  to  hemorrhage  unusual;  direct  transfusion  of  blood,  resorted 
to  for  the  double  purpose  of  overcoming  the  result  of  excessive  hemor- 
rhage and  introducing  into  the  circulation  blood  which  will  be  more 
nearly  normal  for  correction  of  the  hemorrhagic  tendency;  by  intra- 
venous infusion;  proctoclysis,  rectal  administration  and  hypodermoclysis 
(directly  into  the  tissues),  normal  salt  and  other  solutions  are  also 
introduced  into  the  system  to  overcome  both  the  effect  of  and  tendency 
to  hemorrhage;  heat,  cold,  position,  and  pressure  are  useful  adjuncts  in 
arresting  the  flow  of  blood  to  an  affected  part. 


40  ANESTHESIA— HEMORRHAGE— SHOCK 

Certain  details  of  surgical  technic  belong  more  properly  to  text- 
books covering  elementary  surgical  principles,  but  both  immediate  and 
secondary  hemorrhages  may  be  important  features  in  many  mouth  and 
jaw  operations.  This  is  especially  true  in  cases  of  hemophilia,  when 
large,  raw,  periosteal  surfaces  are  exposed,  and  direct  control  of  minute 
vessels  from  which  serious  oozing  may  take  place  is  exceedingly  diffi- 
cult or  perhaps  impossible,  and  for  this  reason  it  seems  advisable  to 
describe  briefly,  yet  with  necessary  detail,  the  various  methods  of 
meeting  these  emergencies. 

Preparatory  Measures. — Careful  examination  of  the  blood,  especially 
the  hemoglobin,  is  always  a  safe  procedure  preliminary  to  every  grave 
surgical  operation,  and  is  imperative  whenever  indications  point  to 
unfavorable  blood  conditions.  Sometimes  these  cannot  be  satisfac- 
torily overcome,  and  the  necessity  of  immediate  operation  is  so  urgent 
as  to  preclude  corrective  attempts.  When  permissible,  tonics,  good 
hygiene,  and  nourishing  food  may  be  greatly  beneficial.  Tendency  to 
hemorrhage  may  also  be  reduced  by  the  administration  of  calcium 
lactate,  or  adrenalin  or  suprarenal  extract,  for  several  days  before 
operation.  All  these  have  been  employed  ^^■ith  more  or  less  satisfac- 
tory results.  The  possibility  of  hemophilia  should  be  recognized  by  a 
careful  study  of  family  history  and  records;  and  questions  should  be 
asked  to  determine  whether  other  members  of  the  family  have  been 
bleeders.  Swelling  of  the  joints  is  almost  constantly  present  in  these 
individuals,  and  this  indication,  if  sought  for,  may  at  least  serve  to 
place  the  operator  on  his  guard. 

The  coagulation  time  of  the  blood  of  the  patient  should  be  taken 
before  operation.  In  this  way  much  danger  may  be  avoided.  The 
author  has  found  the  Boggs  coagulometer  very  satisfactory  for  this 
purpose.  Its  use  should  be  a  routine  measure  in  all  cases  wherever 
possible. 

Treatment  of  Grave  Hemorrhage.- — It  is  assumed  that  the  operator 
has  made  careful  incisions,  as  elswhere  described,  of  such  form  as  to 
favor  the  firm  retention  of  gauze  packing  if  required,  and  that  he  has 
carefully  ligated  all  vessels  of  sufficient  size  to  be  consequential  factors. 
Under  these  circumstances  hemorrhage  which  cannot  be  controlled  by 
ligature,  direct  application,  or  packing  necessitates  the  employment 
of  other  more  general  measures. 

The  position  of  the  patient  by  raising  the  body  or  the  head  of  the  bed 
may  be  helpful.  Clamjnng  or  ligation  of  the  external  carotid,  the  facial 
and  lingual  arteries  will  be  described  later  (Chapter  VI).  Cold  appli- 
cations in  the  form  of  ice  packs,  cloths  wrung  in  ice-water  and  placed 
about  the  head,  face,  and  neck  and  heat  applied  to  the  extremities, 
are  sometimes  helpful  expedients.  Compression  with  rubber  bands 
around  the  arms  close  to  the  shoulders  and  the  thighs  near  the  hips 
will  be  described  later  (Chapter  VI).  For  internal  medication,  ergot 
administered  internally,  ergotin  hypodermically,  powdered  ferropyrin 


HEMORRHAGE  41 

in  20  per  cent,  solution,  and  other  similar  remedies  have  been  quite  gen- 
erally used  and  recommended.  In  the  author's  experience,  however, 
they  are  not  sufficiently  effective  to  meet  the  requirements  of  surgical 
mouth  wounds  in  serious  cases.  Calcium  lactate,  5  to  20  grains  every 
three  of  four  hours  by  mouth,  supplemented  by  thirty  drops  per  rectum 
once  or  twice  daily,  seems  to  increase  the  coagulability  of  the  blood 
appreciably.  In  the  author's  cases,  when  hemorrhage  has  been  so 
controlled  by  packing  that  only  a  slight  oozing  of  blood  can  take  place, 
thus  allowing  a  period  of  several  days  to  get  control  of  the  blood  con- 
ditions without  serious  injury  to  the  patient,  treatment  of  this  kind  has 
proved  to  be  exceedingly  beneficial. 

Adrenalin  (1  to  1000)  given  internally  in  10-  to  30-minim  doses  every 
two  or  three  hours  also  has  a  beneficial  effect,  and  when  hemorrhage 
is  more  profuse,  prompt  action  may  be  secured  by  the  hypodermic 
injection  of  10  to  20  minims.  Pituitary  extract  is  now  highly  recom- 
mended as  having  a  prompt,  more  powerful,  and  longer  continued 
effect  than  the  adrenalin.  Gelatin,  2  yer  cent,  to  3  'per  cent,  in  normal 
saline  solution,  given  by  hj^jodernioclysis,  is  among  the  valuable 
remedies;  but  since  attention  has  been  called  to  the  frequency  with 
which  tetanus  has  followed  this  use,  extreme  care  in  the  sterilization 
of  the  gelatin  solution  should  be  taken. 

Coagulose  (Hemostatic  Ferment). — Coagulose,  a  blood  serum  obtained 
by  precipitating  hosre  serum  by  means  of  a  suitable  mixture  of  acetone 
and  ether,  is  fully  as  effective  as  fresh  serum.  It  is  supplied  in  15  c.c. 
glass  bulbs  which  contain  0.65  gram  of  the  desiccated  powder,  equiva- 
lent to  10  c.c.  of  blood  serum,  and  can  be  used  to  advantage  for  local 
application  to  staunch  persistent  oozing  of  blood,  or  by  injection,  to 
increase  coagualbility.  The  author  has  found  it  very  useful  in  a 
number  of  cases  of  serious  hemorrhage.  The  great  advantages  are 
that  this  preparation  does  not  deteriorate  with  ordinary  care  for  a 
period  of  one  year,  and  that  it  is  always  ready  for  immediate  use. 

Thromboplastin. — Thromboplastin  is  tissue  juice  made  from  brain  and 
thromboplastin  solution.  It  is  claimed  that  it  gives,  upon  local  appli- 
cation, just  the  necessary  properties  to  promote  coagulation.  Throm- 
boplastin hypodermic  is  used  hypodermically  for  the  same  purpose. 
The  author's  experience  with  these  remedies  is  confined  to  a  few  cases 
and  is  by  no  means  conclusive.  Theoretically,  however,  they  promise 
much  usefulness. 

Direct  Transfusion  of  the  Blood.— The  introduction  of  blood  directly 
from  the  artery  of  a  healthy  person  into  the  vein  of  one  affected  by  an 
uncontrollable  hemorrhage,  or  suffering  from  the  effect  of  excessive 
loss  of  blood,  is  the  best  measure  for  extreme  cases. 

The  technic  of  the  operation  as  performed  by  Crile  and  described 
in  concise  form  by  Brewer  is  as  follows: 

"The  recipient  and  donor  are  placed  on  two  tables  and  their  arms 
prepared  in  the  usual  manner.     Under  cocain  anesthesia  the  radial 


42  ANESTHESIA— HEMORRHAGE— SHOCK 

artery  of  the  donor  is  exposed  for  about  two  inches  and  hgated  at  its 
distal  extremity.  A  temporary  clamp  is  next  placed  on  its  proximal 
end  and  the  artery  divided  near  the  ligature.  The  redundant  layer 
of  the  adventitia  is  drawn  outward  and  cut  off,  and  the  vessel  threaded 
through  the  lumen  in  the  cannula  (P^ig.  15).  The  lumen  of  the  vessel 
is  then  grasped  by  thin  equidistant  mosquito  forceps  and  drawn  back- 
ward over  the  distal  end  of  the  cannula,  forming  an  inverted  cuff  with 
intima  downward.  This  is  held  in  i)lace  b\'  a  ligature  of  fine  silk 
placed  over  the  second  groove.  The  vein  of  the  donor  is  prepared 
in  the  same  manner,  its  lumen  exposed  by  three 
small  clamps,  and  drawn  over  the  inverted  arterial 
cufi"  on  the  cannula.  The  two  are  secured  in  place 
by  a  second  ligature  placed  over  the  first  groove, 
which  securely  holds  the  vessels  in  contact.  The 
temporary  clamps  are  next  removed  and  the  blood 
tons'fusionTanniS  allowcd  to  flow  into  the  Vein  of  the  recipient.  The 
X  2.    (Brewer.)  flow  at  first  is  ofteu  slow,  owing  to  the  contraction 

of  the  artery  from  exposure.  The  application  of 
wet  compresses  at  a  temperature  of  108°  to  112°  F.  will  generally 
bring  about  relaxation  of  the  arterial  walls,  and  a  vigorous  flow  of 
blood  follows,  which  causes  marked  pulsation  in  the  vein. 

"The  above  technic,  while  not  particularly  difficult  to  one  who  has 
had  an  opportunity  of  rehearsing  the  operation  either  upon  an  animal 
or  the  cadaver,  is  often  attended  by  certain  embarrassments,  especially 
in  young  children." 

Brewer  simplifies  the  operation  by  the  use  of  glass  tubes  shown  in 
Fig.  16,  which  are  sterilized,  dipped  in  melted  paraffin,  and  allowed 
to  cool.  The  paraffin  which  adheres  to  the  inner  surface  he  has  proved 
by  experimentation  upon  dogs  will  eventually  prevent  coagulation  of 
the  blood.     He  describes  his  operation  as  follows: 

"The  technic  of  this  operation  is  simple,  and  consists  in  exposing 
the  radial  artery,  dividing  it,  drawing  the  proximal  end  over  one 
extremity  of  the  glass  tube  and  securing  it  by  a  silk  ligature,  then  intro- 
ducing the  opposite  end  of  the  tube  into  the  proximal  end  of  a  divided 
vein  and  securing  it  in  the  same  manner.  As  soon  as  the  temporary 
clamps  are  removed  from  the  vessels,  blood  is  readily  transfused  from 
one  individual  to  the  other."^ 

Dr.  Robin  Ottenberg,  of  New  York,^  describes  his  method  of  direct 
blood  transfusion  as  follows:  "It  consists  in  the  use  of  a  small  silver 
ring  whose  surface  has  two  grooves.  The  ring  is  held  by  a  self-retain- 
ing spring  forceps,  which  greatly  facilitates  the  procedure.  The  cut 
end  of  one  of  the  divided  vessels  to  be  anastomosed  is  pushed  through 
the  ring  and  turned  back  over  it  like  a  cuff  (Figs.  17,  18  and  19).     This 

1  Brewer:  Text-book  of  Surgery,  pp.  151  and  152. 

2  Annals  of  Surgery,  April,  1908,  pp.  486  to  488. 


HEMORRHAGE 


43 


cuffing  is  very  easily  done  if  the  open  lip  of  the  vessel  is  caught  at  three 
points  in  its  periphery  by  three  tension  sutures  of  fine  silk. 

"This  cuft'  is  then  tied  in  place  by  a  piece  of  fine  silk  in  the  posterior 
groove,  and  the  other  \'essel  is  pulled  over  it.  Then  at  once  the  two 
vessels  are  fastened  together,  intima  to  intima,  by  two  fine  pieces  of 
silver  wire,  which  fit  into  the  two  grooves."  (The  instruments  used 
are  sIr^nu  in  Figs.  20,  21  and  22.) 


Fig.  16. — Brewer's    glass  cannuliB  for  direct  transfusion,  showing  paraffin  coating 

inner  surface. 


Indirect  Transfusion  of  Blood.^Percy^  recommends  the  following 
method:  "The  tube  consists  of  a  glass  cylinder  4  cm.  in  diameter, 
with  a  cannula  leading  from  one  end,  the  other  end  being  drawn  out 
into  a  tube  about  1  cm.  in  diameter  to  which  a  Y  connection  is  made. 
To  one  arm  of  the  Y,  a  rubber  tube  is  attached  for  suction  to  aid  in 
filling  the  tube,  and  to  the  other  arm  a  rubber  bulb  is  connected  to  aid 
in  injecting  the  blood. 

"The  cannula  part  of  the  tube  is  so  constructed  that  it  can  be 
inserted  directly  into  the  vein  of  the  donor  and  then  the  recipient. 
(See  Fig.  23.) 

'  Surg.,  Gynec.  and  Obst.,  September.  1915. 


44 


ANESTHESIA— HEMORRHAGE— SHOCK 


"The  dangers  of  transfusion  are  two;  i.  e.,  immediate  and  delayed. 
The  immediate  dangers  are  emboHsm  either  from  air  or  clotted  blood, 


Fig.  17. — Ring  and  self-retaining  forceps  in  place,  and  vessel  prepared  for  turning  back 

to  form  cuff. 


Fig.  18. — Cuff  tied  ready  to  have  vessel  pulled  over  it. 


Fig.   19. — Vessel  drawn  over  cuff  and  tied  ready  for  transfusion  of  the  blood. 


HEMORRHAGE 


45 


or  acute  dilatation  of  the  heart  consequent  to  such  rapid  inflow  of 
blood  that  the  recipient's  heart  is  overwhelmed.  The  delayed  danger 
is  that  from  hemolysis,  which  danger  cannot  always  be  eliminated  by 
the  most  careful  tests  prior  to  the  operation. 


Fig.  20  Fig.  21  Fig.  22 

Figs.  20,  21  and  22. — Ottenberg's  instruments  for  blood  transfusion. 


B  II  Y         '^li^H 

«i!iiiiiiiiiiiiiiiiliiliiiii|iii&it!itii^^  iiiiiiii*^?ioii|i5 


Fig.  23. — Instrument  used  in  indirect  method  of  transfusing  blood.     Percy's 
modification  of  the  Brown  tube. 


"To  guard  against  hemolysis  preliminary  tests  should  be  made  except 
when  emergency  conditions  are  prohibitive.  All  syringes,  glassware 
and  other  instruments  used  in  the  tests  are  dry  sterilized.  Twenty  c.c. 
of  blood  are  drawn  from  a  vein  of  the  donor,  and  a  like  amount  from  a 
vein  of  the  recipient.  Each  is  subjected  to  the  following  treatment: 
Five  c.c.  may  be  placed  in  a  test-tube  containing  glass  beads,  and  the 
tube  shaken  for  five  minutes.     This  defibrinates  the  blood  with  result- 


46  A  NFS  THESIA—HEMO  RRHA  GE— SHOCK 

ant  corpuscles.  The  remaining  15  c.c.  of  blood  are  placed  in  a  test-tube 
on  a  slant  and  kept  at  room  temperature  until  clotting  has  taken  place. 
Then  it  is  placed  in  an  incubator  at  37°  C.  to  facilitate  precipitation 
of  the  serum.  The  defibrinated  blood  is  washed  and  centrifuging  in 
physiological  salt  solution  of  the  washed  corpuscles,  a  5  per  cent,  sus- 
pension is  made  by  taking  0.5  c.c.  of  corpuscles  and  8.5  c.c.  of  saline. 
Of  this  5  per  cent,  emulsion  of  red  corpuscles  0.5  c.c.  is  used,  the  cells 
of  the  donor  are  treated  with  a  serum  of  the  recipient  and  the  cells  of 
the  recipient  are  treated  with  the  serum  of  the  donor.  Control  of  the 
saline  corpuscles  of  both  are  made. 

"  If  the  blood  cells  remain  as  a  layer  in  the  bottom  of  the  test-tubes 
and  there  is  a  clear,  nearly  colorless  fluid  above,  or  if  the  tube,  when 
shaken,  be  quite  cloudy  and  not  transparent,  there  has  been  no  hemol- 
ysis. If  there  are  no  red  cells  present  as  a  layer,  or  if  the  shaken 
tube  is  clear,  there  has  been  hemolysis  of  the  red  cells.  The  two  con- 
trol tubes  should  show  no  hemolysis.  If  they  do,  there  has  been  an 
error  in  technic. 

^'Preparation  of  Tvhe. — The  tube  should  be  cleansed  by  washing 
with  water,  alcohol,  and  then  with  ether,  and,  after  it  is  perfectly 
dry,  two  ounces  of  melted  grocer's  paraflEin  is  poured  into  the  tube 
through  the  upper  end.  It  is  then  wrapped  in  a  towel  and  placed 
in  a  steam  autoclave  for  fifteen  minutes  under  fifteen  pounds  of  pres- 
sure, after  which,  with  sterile  rubber  gloves  over  the  hands,  the  tube  is 
rolled  around  while  cooling  so  that  every  part  of  the  inside  is  covered 
\\ith  melted  paraffin  and  any  excess  allowed  to  run  out  of  the  large 
end  (D).  Care  should  be  taken  not  to  allow  the  cannula  to  become 
plugged  with  paraffin.  If  it  does,  the  tip  is  warmed  over  a  flame  and 
the  paraffin  allowed  to  run  back  into  the  tube.  Sterilizing  the  rubber 
tubing,  glass  Y,  and  mouth-piece  is  done  by  placing  them  in  a  towel 
and  autoclaving  in  the  same  way  and  at  the  same  time  as  the  trans- 
fusion tube,  or  boiling  them  for  twenty  minutes.  The  atomizer  bulb 
is  thoroughly  washed  with  alcohol  to  sterilize  it.  When  ready  to  use, 
the  connections  are  all  made  and  two  ounces  of  sterile  liquid  paraffin 
aspirated  into  the  tube  through  the  cannula  by  means  of  suction  at 
the  mouth-piece. 

"  Technic  of  Transfusing  the  Blood. — The  arms  of  both  the  donor 
and  the  recipient  are  prepared  as  for  surgical  operation.  An  ordinary 
blood-pressure  apparatus  placed  about  the  arm  and  pumped  up  to  60 
to  80  mm.  of  mercury,  depending  upon  the  rapidity  with  which  the 
blood  flows,  makes  an  excellent  constrictor.  By  this  means  the  venous 
circulation  is  impeded,  but  not  the  arterial. 

"Under  local  anesthesia,  using  0.5  per  cent,  novocain  solution  intra- 
dermally,  an  incision  is  made  over  the  cephalic  vein  just  above  the  elbow 
on  both  the  donor  and  the  recipient,  and  a  ligature  placed  about  the 
vein  in  its  proximal  portion  in  the  donor  and  in  its  distal  portion  in  the 
recipient.     Small  Carrel  clamps  are  placed  on  that  portion  of  the  vein 


HEMORRHAGE  47 

away  from  the  ligature  in  each  patient  and  a  longitudinal  incision  3  mm. 
long  made  through  all  coats  of  each  vein  midway  between  clamp  and 
ligature.  Small  retention  clamps  are  placed  on  the  two  edges  of  the 
incision  in  each  vein  in  order  to  hold  them  open.  The  cannula  is 
placed,  pointing  distally  into  the  vein  of  the  donor,  and  the  Carrel 
clamp  released  from  the  vein.  By  means  of  suction  at  the  mouth- 
piece, venous  blood  is  drawn  into  the  tube  up  to  the  required  amount. 
The  blood  is  well  protected  from  the  sides  of  the  glass  by  the  paraffin 
coat  and  from  the  air  by  the  liquid  paraffin  which  floats  over  and  com- 
pletely covers  the  blood.  As  soon  as  the  tube  is  filled,  which  in  our 
experience  a^'erages  about  three  and  one-half  minutes  to  withdraw 
600  c.c.  of  blood,  the  aspirating  tube  is  clamped,  the  cannula  removed 
from  the  vein  and  the  small  clamp  reapplied  to  the  donor's  vein. 

"The  cannula  is  now  quickly  placed  in  the  lumen  of  the  vein  of  the 
recipient  and  the  Carrel  clamp  released.  The  blood  will  now  flow 
into  the  vein  of  the  recipient  toward  the  heart,  the  velocity  of  which 
flow  may  be  controlled  by  careful  pumping  of  the  rubber  atomizer 
bulb.  As  soon  as  it  is  evident  that,  the  blood  is  flowing  properly,  an 
assistant  may  release  the  constrictor  from  the  donor  and  ligate  the 
vein  distally  to  the  opening  from  which  the  blood  has  been  taken.  Not 
more  than  five  minutes  should  be  utilized  in  obtaining  the  blood,  nor 
more  than  five  minutes  in  injecting  it.  The  length  of  time  required 
to  fill  the  tube  with  blood  varies  with  different  donors.  It  is  well 
to  have  two  tubes  ready,  so  that  if  it  is  found  that  the  first  tube  fills 
slowly,  taking  more  than  five  minutes  to  get  the  required  amount,  the 
process  may  be  repeated  with  the  second  tube,  aspirating  only  the 
remainder  of  the  required  amount  of  blood."  500  to  850  c.c.  of  blood 
may  be  given  at  one  time. 

Paraffin  seems  to  be  the  best  anticoagulative  agent  for  purposes  of 
transfusion. 

Herudin  (leech  extract),  the  citrate  of  sodium,  and  the  metaphos- 
phate  of  sodium  have  sometimes  been  satisfactorily  employed  for  this 
purpose. 

Intravenous  Infusion  of  Normal  Salt  Solution.— This  has  a  prompt 
eft'ect  upon  the  circulation.  When  a  large  quantity  of  blood  has  been 
lost  it  quickly  supplies  the  circulating  medium  for  the  vessels  and  for 
heart  action,  gives  immediate  general  stimulation,  and  is  of  material 
assistance  in  helping  to  combat  toxic  elements.  While  not  so  com- 
pletely efficient  in  grave  conditions  of  shock,  collapse,  and  uncontrol- 
lable hemorrhage  as  the  direct  transfusion  of  blood,  its  simplicity  and 
the  readiness  with  which  it  can  be  performed  without  preparations 
which  may  in^'olve  delay  make  it  a  useful  therapeutic  measure  that 
is  more  po"werful  than  other  methods  of  saline  administration.  The 
apparatus  used  is  very  simple  (Fig.  24),  and  may  be  even  more  so  in 
emergency,  as  an  ordinary  funnel  attached  to  rubber  tubing  and  an 
eyeglass  dropper  can  be  utilized.     A  superficial  vein  is  exposed.     Usu- 


48  A  NEST  HE  SI  A  —HEMORRHA  GE— SHOCK 

ally  the  median  cephalic  or  basilic  vein  is  chosen.  Compression  for  a 
{e\\  moments  causes  the  vein  to  become  prominent  and  facilitates  the 
operation.  A  short  incision  is  made,  the  vein  cleared  and  ligated  above 
the  point  of  the  ligature,  the  cannula  is  introduced  through  a  small 
incision  which  is  made  for  the  purpose,  and  fixed  in  position  by  a 
second  ligature.  Great  care  should  be  exercised  to  make  sure  that 
both  tube  and  cannula  are  filled  with  solution  before  introduction  to 
prevent  air  being  forced  into  the  vein. 


Fig.  24. — Funnel  and  tube  for  intravenous  injection.     (Brewer.) 

The  temperature  of  the  sterile  salt  solution  should  be  from  110°  to 
118°  F.  It  should  be  slowly  introduced  unless  there  be  pressing  need 
of  haste,  and  a  quantity  ^^■hich  may  vary  from  1  to  4  or  5  pints  allowed 
to  flow  into  the  veins,  this  being  measured  by  the  nature  and  exigencies 
of  the  case  and  the  effect  upon  the  patient.  Normal  salt  solution  may 
be  prepared  by  adding  130  grains  of  pure  sodium  chloride  to  one  quart 
of  sterile  water. 

Roswell  Park's  Balanced  Physiological  Solution  is  as  follows :  Sodium 
chloride,  0.09;  potassium  chloride,  0.03;  calcium  chloride,  0.02;  sterile 
water,  100. 

Hypodermoclysis.-^Hypodermoclysis  is  the  subcutaneous  injection 
of  saline  or  other  solutions  in  large  quantity.  For  this  purpose  an 
irrigator  connected  with  a  rubber  tube  having  a  long  aspirating  needle 
attached  is  used.  Both  the  apparatus  and  the  solution  must  be  care- 
fully sterilized.  The  aspirating  needle  is  thrust  through  the  skin  into 
some  fleshy  part  of  the  body,  such  as  the  abdomen,  thorax,  thigh, 
buttock,  etc. 

The  skin  is  first  cleansed  with  alcohol.  One  or  two  pints  of  normal 
salt  solution  are  allo^^■ed  to  infiltrate  the  tissues.  The  distention  of  the 
parts  immediately  surrounding  the  needle  point  is  reduced  by  gentle 
massage,  which  facilitates  absorption.  This  treatment  is  usually 
sufficiently  marked  and  prompt  for  ordinary  cases,  and  has  the  advan- 
tage that  any  capable  nurse  may  employ  it  instantly  upon  indication 


HEMORRHAGE  49 

for  its  use.  Thus,  the  frequently  grave  delay  of  waiting  for  a  surgeon 
capable  of  performing  the  more  serious  operative  procedures  incident 
to  the  methods  of  blood  transfusion  or  saline  intravenous  infusion  is 
avoided. 

Proctoclysis.— The  slow,  drop-by-drop  introduction  of  normal  salt 
solution  into  the  rectum  or  colon,  a  period  of  thirty  minutes  or  one  hour 
or  more  being  required  for  a  pint  or  quart,  is  a  valuable  remedy  in 
reduced  systemic  states  from  long-continued  fevers,  intestinal  diseases, 
and  kindred  conditions.  It  is  also  used  in  postoperative  treatment  to 
replace  fluid  lost  from  the  circulation  through  hemorrhage,  to  supply 
active  general  stimulation,  to  relieve  thirst  following  anesthesia,  and  to 
give  a  generally  soothing  effect.  The  addition  of  small  quantities  of 
coffee  or  whisky  adds  materially  to  the  beneficial  result.  The  intro- 
duction of  saline  solutions  during  the  continuance  of  grave  hemorrhage 
is  objected  to  because  it  is  claimed  that  the  flow  of  blood  is  increased 
thereby,  but  when  the  hemorrhage  has  been  checked  it  sometimes 
gives  marked  assistance  in  recovery. 

Hemophilia  Treated  by  Transfusion.— The  following  cases  have  been 
selected  for  description  because  of  their  features  of  special  interest: 

Case  I. — Francis  C.  Allen  has  described  the  case  of  a  boy,  aged 
twelve  years,  who  entered  the  hospital  with  a  history  of  having  bled 
from  the  mouth  for  four  days  previously.  The  bleeding  had  been 
profuse. 

On  admission,  the  patient  was  comatose,  very  pale,  the  skin  was 
flabby  and  waxy,  and  a  thin  stream  of  blood  was  oozing  from  the  mouth. 

He  was  treated  for  two  days  with  various  drugs  and  with  saline 
solution  subcutaneously.  The  oozing  continued,  and  the  boy  became 
weak  and  more  deeply  unconscious.  The  hemoglobin  on  the  day  of 
admission  would  not  register  on  the  hemoglobinometer,  which  does  not 
register  below  10,  but  the  resident  physician  estimated  it  as  5. 

The  second  day  after  admission,  with  an  uncle  of  the  child  as  the 
donor,  a  small  amount  of  blood  was  transfused,  but  how  much  it  was 
impossible  to  state.  During  the  operation  the  boy's  mental  condition 
changed,  and  he  became  bright  enough  to  complain  of  pain  and  to  call 
the  doctor  hard  names. 

Two  days  after  operation  the  hemoglobin  had  risen  from  5  to  14, 
and  the  red  cells  from  1,060,000  to  1,240,000.  The  bleeding  stopped 
after  the  transfusion,  but  recurred  slightly  at  intervals  for  the  next  five 
or  six  weeks.     The  hemoglobin  continued  to  increase. 

On  June  4,  one  month  after  admission,  the  hemoglobin  registered  68, 
and  the  red  cells  3,930,000.  The  boy  was  discharged  in  good  condi- 
tion, the  only  thing  observable  being  that  the  teeth  were  carious  and 
very  irregular.  It  was  almost  impossible  to  ascertain  the  source  of 
the  bleeding;  at  times  it  seemed  to  come  out  of  the  teeth  themselves, 
two  of  which  were  mere  shells ;  at  other  times  it  seemed  to  come  from 
the  edges  of  the  gums. 
4 


50  ANESTHESIA— HEMORRHAGE— SHOCK 

The  boy  has  been  back  to  the  hospital  three  or  four  times  since. 
During  the  following  winter  he  was  admitted  with  hemoglobin  regis- 
tering 15.  Blood  was  not  transfused  on  this  occasion,  but  he  was 
treated  medically.     The  hemoglobin  gradually  rose. 

Case  II. — Report  of  case  of  Dr.  Cobb,  Medical  Officer  in  Command, 
United  States  Public  Health  and  Marine  Service,  Milwaukee. 

C.  B.,  aged  twenty-two  years,  born  in  United  States,  admitted  to 
St.  Mary's  Hospital,  Milwaukee,  September  6,  1909.  Discharged 
December  10,  1909,  recovered. 

Family  History. — ^There  is  a  distinct  family  history  of  bleeders. 
Grandfather  on  mother's  side  is  living  and  is  a  bleeder.  All  of  six  sons 
of  his  mother's  sisters  are  bleeders.  One  brother  of  this  patient  bled 
to  death,  and  his  other  brother  is  a  bleeder.  Today,  September  10, 
blood  count,  red  corpuscles,  2,250,000;  white  corpuscles,  13,125; 
hemoglobin,  35  per  cent. 

When  admitted  had  foul  tongue,  temperature  101°,  and  muddy, 
yellowish  skin,  typical  of  infection.  Tumor  in  iliac  fossa  which 
gradually  increased  in  size  until  September  4. 

Operation. — An  incision  about  four  inches  long  was  made  down 
through  the  abdominal  muscles  to  the  tumor.  It  had  the  appearance 
of  a  hematoma.     A  trocar  was  inserted  and  pure  blood  returned. 

The  next  day  a  blood  count  was  made,  which  showed  15,000  whites, 
2,400,000  reds,  and  hemoglobin,  50  per  cent.  On  September  6,  hemo- 
globin, 40  per  cent.;  September  9,  red  blood  count,  1,800,000;  whites, 
15,900;  hemoglobin,  28  per  cent. 

The  tumor  increased  rapidly  in  size  after  the  operation  and  oozed 
slightly  from  the  day  of  operation.  By  September  10  the  tumor  was 
noticeably  bulging  through  the  wound.  During  the  night  of  Septem- 
ber 13  the  blood  began  to  spout  in  a  fine  stream.  To  control  the  bleed- 
ing a  median  incision  was  made  in  the  abdomen  large  enough  to  admit 
the  hand.  Through  this  an  assistant  controlled  the  common  iliac 
artery.  Then  the  tumor  was  hastily  laid  open  and  the  great  mass  of 
black,  clotted  blood  turned  out.  With  gauze  ready  to  pack,  the  iliac 
artery  was  released.  There  was  no  gush  of  blood,  as  was  expected. 
There  was  no  damage  to  any  large  bloodvessel,  but  there  was 
rapid  oozing  from  the  walls  which  filled  the  tumor  sac.  The  sac  was 
firmly  packed,  the  median  wound  closed,  and  the  patient  returned 
to  bed. 

When  the  first  packing  was  removed  the  wound  was  filled  with 
ferropyrin.  This  was  continued  until  September  24.  The  patient 
was  given  calcium  lactate  in  maximum  dosage  up  to  September  20. 
On  the  latter  date  we  began  the  subcutaneous  injection  of  100  c.c 
of  a  2  per  cent,  gelatin  solution.  This  was  given  every  day.  Still  the 
patient  bled  every  day  some  time  between  one  and  five.  October  1, 
gave  3000  units  of  antidiphtheritic  serum.  No  change.  Dr.  G.  V.  I. 
Brown  suggested  the  Crile  transfusion.     Dr.  John  L.  Yates,  of  Mil- 


HEMORRHAGE  51 

waukee,  performed  the  operation  of  blood  transfusion  by  the  Crile 
method  October  4.  '^I'he  effects  were  immechate.  The  red  count  was 
5,000,000  on  the  morning  of  October  5.  The  hemoglobin  was  75  per 
cent.  The  patient  (Hd  not  bleed  again.  In  five  days  the  red  count  was 
5,400,000  and  hemoglobin  92  per  cent.  The  wound  cavity,  which 
extended  to  the  kidney  above  and  filled  the  iliac  fossa,  had  showed  no 
tendency  to  heal  as  long  as  there  was  bleeding,  but  it  began  to  fill  in 
rapidly  after  the  transfusion. 

Patient  bled  thirty-two  days.     Discharged  December  10,  1909. 

The  following  is  a  personal  report  of  a  case  of  subcutaneous  injection 
in  small  quantities  of  human  blood  in  spontaneous  hemorrhage  of  the 
newborn,  by  Dr.  A.  W.  Myers,  of  Milwaukee. 

At  noon  on  June  20,  when  the  child  was  thirty-two  hours  old,  a  large 
stool  was  expelled  composed  entirely  of  tarry  blood  clots.  This  was 
repeated  at  2,  3,  4,  5,  6,  and  8  p.m.  At  4,  6,  and  8  p.m.  the  expulsion 
of  the  bloody  stools  was  accompanied  by  vomiting  of  considerable 
quantities  of  clotted  blood. 

During  the  night  the  child  slept  quietly  until  4  a.m.,  when  there 
was  a  bloody  stool  with  vomiting  of  blood.  This  was  repeated  at 
7  A.M.,  and  at  10  and  11.30  a.m.  there  were  bloody  stools  without 
vomiting. 

When  seen  at  noon  of  June  21  the  child's  condition  seemed  almost 
hopeless;  the  weight  had  fallen  to  4  pounds  8  ounces,  the  mucous 
membranes  were  very  pale,  the  skin  was  colorless.  The  cord  was 
normal,  no  bleeding  occurred  at  this  point,  and  there  were  no 
hemorrhages  into  the  skin  or  the  visible  mucous  membranes. 

Three  c.c.  of  blood  were  drawn  from  a  vein  of  the  mother's  arm  and 
quickly  injected  into  the  subcutaneous  tissues  of  the  baby's  buttock 
before  there  was  time  for  the  bood  to  coagulate  in  the  syringe.  This 
was  done  at  12  m. 

At  2.30  P.M.  a  stool  was  passed  containing  rather  old-looking  clots 
and  a  small  amount  of  fresh  blood. 

At  4.30  P.M.  a  second  injection  of  maternal  blood  was  given  into 
the  other  buttock.     There  was  absolutely  no  more  bleeding. 

The  child  was  put  to  the  breast  and  nursed  well  after  the  first  few 
times.  There  was  no  more  vomiting,  and  the  following  stools  presented 
the  typical  meconium  character,  gradually  changing  to  the  milk-stool 
appearance  in  a  few  days. 

The  blood  injected  was  quickly  absorbed,  and  a  few  hours  afterward 
the  site  of  injection  could  be  recognized  only  by  the  needle  puncture 
in  the  skin. 

The  subsequent  history  of  the  child  was  uneventful.  On  June  23 
the  weight  was  4  pounds  10  ounces,  on  July  2,  5  pounds,  and  on  July 
16,  6  pounds. 

Schloss  and  Commisky^  report  7  cases  of  spontaneous  hemorrhage 

1  Am.  Jour.  Dis.  of  Children,  April,  1911. 


52  ANESTHESIA— HEMORRHAGE— SHOCK 

in  the  newborn  treated  in  this  manner,  of  which  6  recovered  and  1  died. 
The  fatal  case  was  in  an  infant  in  a  moribund  condition  from  multiple 
hemorrhages  for  eight  days. 

The  ease  with  ^^•hich  this  method  of  treatment  can  be  carried  out 
under  any  surroundings,  and  the  brilliant  results  reported  by  Schloss 
and  Commisky,  will  do  much  to  commend  it  to  all  svho  have  fre- 
quently encountered  this  alarming  condition. 

Welch  has  reported  12  cases  with  hemorrhage  in  the  newborn 
successfully  treated  by  the  subcutaneous  injection  of  human  blood 
serum. 

Upon  two  occasions  the  author  has  had  2  to  5  c.c.  of  blood  taken 
from  his  own  arm  and  injected  into  the  buttock  when  newly  born 
infants'  blood  failed  to  coagulate  after  hare-lip  operation. 

There  was  more  or  less  induration  surrounding  the  point  of  injection 
in  each  case,  but  the  hemorrhage  ceased. 

If  time  should  prove  that  human  blood  may  be  spontaneously 
injected  in  infants  without  harmful  results,  and  with  prompt  benefit, 
such  as  the  cases  thus  far  reported  have  received,  it  would  be  a  great 
step  forward  in  the  treatment  of  many  other  affections  as  well  as 
spontaneous  hemorrhage  in  the  newborn.  The  direct  transfusion  of 
blood  by  even  the  simplest  method  is  difficult  and  a  more  or  less  slow 
process  because  of  the  smallness  of  the  infant's  vessels,  and  even  the 
preparation  of  serum  requires  more  time  than  is  necessary  for  the 
subcutaneous  injection  of  blood  as  described.  The  time  limit  alone 
may  decide  the  question  of  life  or  death  in  a  critical  situation. 

Experience  with  many  patients  in  w^hich  low  blood  coagulation  has 
been  a  serious  factor  has  impressed  upon  the  author's  mind  the  neces- 
sity for  familiarity  with  every  means  of  controlling  hemorrhage.  Many 
times  this  has  meant  the  saving  of  life.  The  several  methods  of  blood 
transfusion  and  other  treatments  are  therefore  presented  in  this  light. 

SHOCK. 

Shock  is  defined  as  a  depression  of  the  vital  powers  caused  by  painful 
injuries  or  strong  mental  emotion.  According  to  Crile,  "the  central 
nervous  system  is  in  shock  whenever  it  has  been  subjected  to  a 
sufficient  afferent  stimulation  to  produce  pathological  alteration  of 
function." 

Shock  usually  follows  immediately  upoii  the  reception  of  an  injury, 
but  may  appear  some  time  after.  The  author  believes  that  the  effect 
of  deferred  shock  in  long-continued  operations  in  dental  chairs  is  much 
greater  and  more  frequent  than  it  appears  to  be,  and  that  because  the 
s\inptoms  are  not  immediate  their  real  cause  is  not  recognized. 

Etiology. — Psychic  Causes. — The  physical  manifestations  of  purely 
mental  impressions  as  exemplified  in  shock  are  modified  by  many  con- 
ditions related  to  bodily  health,  temperament,  and  other  controlling 


SHOCK  53 

factors;  thus,  sudden  fright,  tJie  Cirect  of  bad  news,  the  stirring  of  some 
memory  center  througli  the  senses,  might  be  shght  or  serious,  or  even 
cause  syncope  and  death,  according  to  the  temperament  or  condition  of 
general  health  of  the  individual,  or  of  some  vital  organ. 

Operative  Causes.— ^The  shock  from  surgical,  operative,  or  other 
injuries  likewise  is  in  a  general  \\ay  proportionate  to  the  character  and 
extent  of  injury,  subject  to  modifying  conditions,  so  that  sometimes 
a  very  slight  traumatism  or  surgical  operation  will  produce  symp- 
toms of  severe  shock,  while  serious  injuries  may  pass  with  but  slight 
disturbance. 

Grave  accidental  injuries  accompanied  by  fright,  such  as  railroad 
or  similar  accidents,  almost  invariably  cause  severe  shock. 

Surgical  shock  is  aggravated  by  the  influence  of  predisposing  potent 
factors,  lowered  vitality,  extremes  of  age  (infancy  and  old  age),  mal- 
mttrition,  exhaustion  (as  from  chronic  disease,  overexertion,  mental  or 
bodily  suffering,  etc.),  diseases  of  the  blood,  kidnei/s,  and  heart,  tuber- 
culosis, syphilis,  chronic  or  acute  nervous  states,  and  pregnancy. 

Direct  Factors.^It  has  long  been  known  that  certain  classes  of 
injuries  are  attended  with  marked  shock,  such  as  injuries  of  the  viscera, 
testicle,  and  much  lacerated  wounds  of  the  trunk  and  extremities. 

Crile  and  Lauer,  from  notes  on  5800  major  operations,  enumerate 
the  factors  in  shock  as  follows: 

"(a)  Psychic  excitation,  such  as  fear,  foreboding,  etc.  This  has 
seemed  to  be  a  more  powerful  factor  than  is  usually  considered. 

"(6)  Hemorrhage,  also  a  self-evident  factor,  and  often  very  diffi- 
cult to  estimate  closely. 

"  (c)  Cold.  The  depressing  effect  of  lowering  the  body  heat,  as  in 
exposure  to  cold  on  battlefields,  undue  exposure  in  the  operating  room, 
and  many  physiological  experiments,  is  well  established.  In  practice, 
Crile  sometimes  places  the  patient  on  a  hot-water  bed,  adapted  to  the 
operating  table. 

"(c?)  Acute  and  chronic  infections.  In  these  there  is  a  marked 
physical  disturbance  of  many  parts  of  the  body,  and  certainly  not  the 
least  is  circulatory  mechanism."^ 

The  primary  and  essential  factor  in  shock  is  an  effect  upon  the  vaso- 
motor centers,  evidenced  by  low^ered  blood-pressure.  The  resulting 
loss  of  vascular  tone  in  the  arteries  with  correspondingly  diminished 
activity  of  the  heart  causes  an  unequal  distribution  of  the  blood. 

As  a  result  the  abdominal  veins  become  distended,  the  right  side 
of  the  heart  engorged,  and  because  the  blood  becomes  lodged  in  the 
paralyzed  and  the  dilated  venous  system  there  is  comparatively  little 
blood  circulation.  This  in  turn  acts  upon  the  central  nervous  system 
and  results  in  impairment  or  cessation  of  its  functions.  Crile's  experi- 
ments on  dogs,  corroborated  by  study  of  human  cases,  has  shown  the 

1  Practical  Medicine,  Series  11,  1906,  p.  82  (after  Jour.  Am.  Med.  Assn.,  June  17,  1905). 


54  ANESTHESIA—HEMORRH  AGE—SHOCK 

effect  of  blood-pressure  on  respiration.  In  90  out  of  103  experiments 
he  found  that  respiratory  faikire  was  the  actual  cause  of  death,  and  that, 
contrary  to  the  generally  accepted  opinion,  the  heart  was  the  one  factor 
most  to  be  depended  upon ;  that  heart  weakness  was  due  to  the  reduced 
amount  of  fluid  in  its  cavities  more  than  to  any  direct  effect  of  the 
shock,  thus  giving  a  practical  basis  for  treatment,  which  has  been  fully 
corroborated  by  the  results  of  blood  transfusion  in  both  animals  and 
man. 

Some  experimental  studies  on  shock  and  hemorrhage  are  reported  by 
F.  C.  Mann^  from  the  Mayo  Clinic. 

In  a  normal  dog  66  per  cent,  of  the  blood  can  be  obtained  from  the 
femoral  and  10  per  cent,  from  the  heart,  lea\-ing  24  per  cent,  in  the 
tissues. 

In  an  animal  in  which  the  C.  cord  is  sectioned,  producing  medul- 
lary vasomotor  paralysis,  54  per  cent,  of  the  blood  can  be  obtained 
from  the  femoral  and  12  per  cent,  from  the  heart,  leaving  34  per  cent, 
in  the  tissues. 

In  an  animal  in  which  blood-pressure  is  depressed  practically  to  zero 
by  an  overdose  of  ether,  46  per  cent,  of  the  blood  can  be  obtained  from 
the  femoral  and  13  per  cent,  from  the  heart,  leaving  41  per  cent,  in  the 
tissues. 

In  an  animal  in  ^^'hich  the  viscera  have  been  exposed  until  the 
clinical  signs  of  shock  are  present  but  in  which  the  vasomotor  reflexes 
are  as  active  or  even  more  so  than  normal,  only  28  per  cent,  of  the 
blood  can  be  obtained  from  the  femoral. 

He  concludes  that  the  clinical  signs  of  shock  which  appear  after 
section  of  the  abdomen  and  exposure  of  the  viscera  are  due  to  a  loss 
of  circulatory  fluid.  This  loss  is  not  dependent  upon  any  primary 
impairment  of  the  medullary  center  and  takes  place  at  a  point  beyond 
the  control  of  the  vasomotor  mechanism.  The  causes  for  this  loss  are 
apparently  the  same  as  those  which  determine  the  accumulation  of 
fluid  in  any  other  irritated  area  and  produce  the  signs  of  inflammation. 
The  nervous  system  probably  plays  no  greater  part  in  the  former  case 
than  in  the  latter.  The  condition  is  made  grave  when  the  viscera  are 
exposed  because  of  the  great  vascularity  of  the  tissues  involved. 

Pike  and  Coombs'^  conclusions  from  their  experimentations  are 
that: 

1.  When  the  cells  of  the  brain  and  medulla  oblongata  are  deprived 
of  blood  for  a  period  of  from  ten  to  twenty  minutes,  a  change 
in  the  staining  reactions  of  the  cells  is  demonstrable  if  the  brain  and 
upper  portion  of  the  spinal  cord  are  removed  some  minutes  after  the 
circulation  to  the  head  has  been  restored.^ 

1  Surg.,  Gynec.  and  Obst.,  October,  1915. 

'  The  Relation  of  Low  Blood-pressure  to  a  Fatal  Termination  in  Traumatic  Shock, 
Jour.  Am.  Med.  Assn.,  June  23,  1917. 

3  Gomez  and  Pike:  Jour.  Exper.  Med.,  1909,  p.  11. 


SHOCK  55 

2.  There  is  a  greater  susceptibility  of  these  previously  damaged 
cells  to  strychnin.  Paralysis  and  failure  of  function  from  adminis- 
tration of  strychnin  during  the  resuscitation  period  occur  more  readily 
in  the  anterior  (cephalic)  portion  of  the  central  nervous  system,  which 
has  been  deprived  of  blood  for  a  time,  than  in  the  posterior  portion 
through  which  the  circulation  has  been  maintained  continuously.^ 

3.  Such  damaged  nerve  cells  will  recover  when  a  proper  supply  of 
oxygenated  blood  is  provided.  Respiration,  blood-pressure  and  pulse 
rate  soon  become  normal.' 

In  some  cases  collapse  or  complete  prostration  doubtless  occurs 
rapidly  from  grave  injury  which  appears  to  be  the  result  of  inhibitory 
reflex  directly  affecting  the  vagus.  The  foregoing  more  or  less  con- 
flicting conclusions  from  experimental  research  with  reference  to  hemor- 
rhage and  shock  will  undoubtedly  be  cleared  up  in  the  near  future, 
as  its  relation  to  the  vegetative  nervous  system  and  vagotonic  con- 
ditions, and  the  influences  which  bear  upon  the  balance  of  control 
between  the  sympathetic  and  vagus  systems  become  better  understood 
in  the  light  of  researches  now  well  under  way  by  many  investigators. 
From  a  surgical  operative  point  of  view,  however,  the  net  result  is 
much  the  same,  for  all  conclusions  point  in  the  direction  of  better 
operative  technic. 

Symptoms. — All  symptoms  of  shock  have  a  certain  resemblance, 
but  for  clinical  convenience  these  are,  so  far  as  possible,  arranged  in 
graduated  order  from  the  milder  to  the  graver  conditions,  as  follows: 

There  is  a  feeling  of  weakness,  giddiness,  and  slight  nausea. 

The  appearance  of  the  face  is  pale,  with  beads  of  cold  perspiration 
upon  the  skin  surface. 

The  extremities  are  cold,  the  pulse  becomes  weak  and  irregular,  and 
syncope  may  occur,  followed  by  partial  or  complete  loss  of  conscious- 
ness. 

Severe  shock  is  indicated  when  restoration  to  consciousness  is  slow 
and  there  is  a  tendency  to  recurrence  after  the  patient  has  been  tem- 
porarily aroused,  when  the  pupils  are  markedly  dilated  and  slow  in 
response  to  light  reaction,  and  when  the  surface  of  the  body  is  cold  and 
clammy  with  perspiration  and  there  is  no  response  to  warmth  or  rub- 
bing, and  when  there  is  a  marked  subnormal  temperature,  and  the 
pulse  unusually  weak,  rapid,  irregular,  and  compressible. 

The  profound  unconsciousness  of  coma  or  delirium,  subnormal,  tem- 
perature of  97°  F.  or  less,  with  unusual  restlessness  or  great  feebleness, 
relaxation  of  the  sphincters,  sighing,  feeble,  irregular,  unusually  slow 
or  exceedingly  rapid  and  shallow  respiration,  with  eyes  rolled  upward 
and  failure  to  respond  to  stimulus  of  any  kind,  are  indications  for  grave 
prognosis. 

1  Stewart  and  others:  Journal  Exper.  Med.,  1906,  pp.  176  and  248. 

2  Pike:  Am.  Jour.  Physiol.,  1912,  xxx,  436-450. 


56  ANESTHESIA— HEMORRHAGE— SHOCK 

Treatment. — Prophylactic, ^ — In  cases  of  accident  or  emergency  there 
is  often  little  opportunity  for  more  than  an  attempt  to  overcome  the 
direct  evidences  of  shock.  When  it  is  possible  to  be  more  deliberate, 
the  mental  attitude  of  the  subject  should  be  kejrt  in  mind,  and  brooding 
over  the  operation  or  a  gloomy  outlook  should  be  avoided  so  far  as 
possible  by  surrounding  the  patient  with  persons  who  are  cheerful, 
hopeful,  and  competent. 

Especially  with  infants,  too  long  a  period  of  starvation  must  be 
avoided.  Nourishment  in  moderate  quantity  should  be  given  from  one 
and  one-half  to  three  hours  before  operation,  according  to  the  age  of 
the  infant.  Starving  babies  bear  shock  badly.  In  older  persons, 
except  those  in  feeble  health,  precaution  of  this  respect  is  not  so  neces- 
sary. The  hypodermic  injection  of  morphin,  gr.  ^  to  \,  with  atropin, 
gr.  120  to  100,  thirty  minutes  before  operation,  or  similar  injections  of 
scopolamin,  gr.  ji-o,  morphin,  gr.  ^,  will  relieve  the  nervousness  and 
make  it  possible  to  secure  complete  anesthesia  with  less  anesthetic, 
besides  reducing  the  danger  of  inspiration  of  mucus  through  control  of 
the  activity  of  glandular  secretion. 

The  operating  room  should  be  warm.  It  is  the  author's  custom  to 
have  infants  and  young  children  lie  upon  a  warm  water  bottle  upon 
an  operating  table  or  upon  his  special  table  arranged  with  a  hot-water 
tank  to  maintain  continuous  warm  temperature.  This  table  was 
designed,  made  and  contributed  by  Dr.  R.  M.  Hall,  of  the  Milwaukee 
Children's  Free  Hospital,  whose  kindness  has  given  much  benefit  to 
many  children.  With  older  persons  the  table  may  or  may  not  be 
warmed.  But  the  body  should  not  be  unnecessarily  exposed  to  chilling 
during  the  operation.  Every  drop  of  blood  that  can  be  saved  reduces 
shock  to  just  that  extent;  every  fractional  part  by  which  the  amount  of 
anesthetic  given  can  be  reduced  not  only  reduces  the  immediate  danger 
of  shock,  but  leaves  just  that  much  less  of  the  depressing  toxic  eflect 
for  the  system  to  overcome  afterward ;  every  moment  by  which  the  time 
of  operation  can  be  reduced  without  undue  haste,  which  might  cause 
neglect  of  important  operative  procedures,  and  every  traumatic  effect 
in  the  handling  of  tissue,  violence  in  sponging,  or  contact  with  impor- 
tant nerves  that  may  be  avoided,  is  just  that  much  accomplished  toward 
relieving  shock  of  its  grave  features.  The  previous  administration  of 
stimulating  drugs,  such  as  strychnin  or  even  whisky,  the  author 
believes  to  be  disadvantageous,  because  if  a  time  should  come  when 
stimulation  of  this  character  is  actually  required  its  effect  cannot  be 
relied  upon. 

After-treatment.- — The  patient  should  be  covered  with  warm  blankets 
and  protected  against  chilling  of  the  body  when  he  is  taken  from  the 
operating  room  to  the  bed,  which  should  previously  have  been  warmed 
with  hot-water  bottles.  He  is  then  wrapped  in  warmed  woollen  blan- 
kets and  the  bodily  temperature  is  maintained  with  water  bottles,  with, 
of  course,  protection  to  prevent  burning  the  body  during  unconscious- 


SHOCK  57 

ness.  Normal  salt  solution,  a  pint  by  the  rectum,  containing  whisky  or 
coffee,  ser^'es  to  restore  circulatory  conditions  and  to  sui)ply  lost  fluid 
in  the  circulation.  It  is  soothing,  tends  to  reduce  the  thirst  for  water, 
and  favors  normal  reaction  in  e^•ery  way.  Quiet,  restful  surroundings 
and  encouraging  assurance  that  all  is  well  ^^■ith  the  first  signs  of  return- 
ing consciousness  often  serve  to  reduce  excitement  and  fa^■or  rest  and 
recovery. 

A  5  per  cent,  solution  of  glucose  may  be  substituted  for  other  stimu- 
lants in  proctoclysis.  Burham'  advises  its  continuous  use  \\hen  neces- 
sary and  states  that  300  to  500  calories  a  day  may  be  introduced  in  this 
way. 

Of  all  the  many  drugs  that  have  from  time  to  time  been  recom- 
mended, the  hypodermic  injection  of  strychnin  appears  to  H.  P.  Cole^ 
to  find  favor  among  the  greatest  number  of  surgeons  (40  per  cent.), 
but  those  in  opposition  to  its  use  hold  that  under  some  circum- 
stances strychnin  rather  aggravates  than  improves  the  condition  in 
shock.^ 

Bandaging. — A  firm  bandage  about  the  abdomen  or  bandaging  the 
extremities,  or  Crile's  pneumatic  suit,  may  be  employed  to  equalize 
the  circulation  and  temporarily  assist  the  heart.  Except  when  contra- 
indicated,  the  patient  should  be  kept  with  the  head  low  during  recovery 
and  the  face  turned  upon  one  side  to  prevent  inspiration  of  the  blood  or 
mucus.  Additional  advantage  in  a  weakened  state  may  be  gained 
by  raising  the  foot  of  the  bed  so  that  the  body  inclines  with  the  head 
slightly  downward. 

Care  should  be  taken  that  normal  salt  solution  given  by  the  rectum 
is  maintained  at  a  sufficiently  high  temperature.  Murphy  has  proved 
that  ordinarily  a  loss  of  several  degrees  occurs  by  the  time  the  salt 
reaches  the  colon.  Some  one  of  the  many  forms  of  keeping  the  solution 
hot  must  be  used,  otherwise  the  effect  may  be  to  decrease  rather  than 
increase  bodily  temperature.  The  salt  solution  is  best  administered 
by  the  drop  method,  slowly,  taking,  if  necessary,  an  hour  for  the 
administration  of  a  pint  of  saline  (p.  48). 

When  the  effect  of  salt  solution  by  the  rectum  is  insufficient,  it  may 
be  given  by  hypodermoclysis  directly  into  the  tissues  (p.  48).  A 
syringe  point  is  made  for  the  purpose  after  the  form  of  a  hypodermic 
needle,  only  somewhat  larger.  It  is  attached  to  the  rubber  tube  con- 
nected with  the  vessel  containing  the  salt  solution,  and  is  forced  into 
the  tissues  in  a  fleshy  part  of  the  body.  The  absorption  of  the  fluid  is 
assisted  by  gentle  manipulation  of  the  tissue  around  the  point.  In 
cases  where  still  more  rapid  reaction  is  required  the  intravenous  injec- 
tion of  saline  solution  (p.  47)  is  indicated.  Mummery  recommends 
the  intravenous  infusion  of  a  solution  of  adrenalin  in  normal  salt 

1  Am.  Jour.  Med.  Sc,  September,  1915. 

2  Southern  Med.  Jour.,  June,  1909. 

3  Mummery,  J.  P.  L.:  Lancet,  April,  1903. 


58  ANESTHESIA— HEMORRHAGE— SHOCK 

solution,  1  to  20,000,  at  the  rate  of  about  3  to  5  c.c.  per  minute,  to  be 
continued  until  blood-pressure  remains  at  a  safe  level.  Crile  urges, 
and  has  demonstrated  beyond  question,  the  value  of  direct  blood  trans- 
fusion according  to  his  method  (p.  41). 

Henderson^  claims  to  have  demonstrated  that  lack  of  carbon  dioxide 
in  the  blood  causes  a  lack  of  venous  tone,  and  this  lack  of  venous  tone 
diminishes  the  amoimt  of  blood  that  reaches  the  auricles  and,  therefore, 
ventricles  of  the  heart  during  diastole.  He  also  states  that  even  when 
the  anesthetic  appears  to  be  sufficient,  the  sensitive  nerves  still  note 
injuries  and  pain,  and  shock  may  be  caused  unless  the  anesthesia  is 
profound.  This  means  clinically  that  anesthesia  should  always  be 
sufficient  before  operation  and  during  operation.  He  claims  that  a 
lowered  arterial  tension  improves  rapidly  when  physiological  saline 
impregnated  with  carbon  dioxide  is  administered  intravenously. 

Henderson  terms  this  condition  of  diminished  carbon  dioxide  content 
of  the  blood  acapnia  (from  the  Greek  l-aimos,  meaning  smoke),  literally 
a  "smokelessness." 

"1.  Severe  pain  should  never  be  allowed;  it  should  be  prevented 
by  enough  of  the  narcotic  which  seems  indicated  in  the  individual 
cases. 

"2.  Anesthesia  should  be  complete  both  before  beginning  operation 
and  during  it. 

"3.  If  shock  occurs  after  operation  or  after  other  injuries,  trans- 
fusion into  the  veins  of  physiological  saline  saturated  with  carbon 
dioxide  should  be  done.  Also,  at  any  time  during  shock,  air  or  oxygen, 
with  moderate  amounts  of  carbon  dioxide,  should  be  inhaled. 

"4.  Whenever  there  is  likelihood  of  pain  following  the  recovery 
of  the  patients  from  anesthesia,  morphin  should  be  injected  to 
prevent  it. 

"5.  However  valuable  strychnin  injections  may  be  as  a  stimulant 
to  the  nerve  centers  and  as  a  stimulant  to  general  metabolism  to  per- 
haps promote  normal  cellular  activity,  and  perhaps,  therefore,  the 
production  of  a  normal  amount  of  carbon  dioxide,  excessive  amount  of 
strychnin  as  a  cardiac  and  respiratory  stimulant  in  shock  should  not 
be  used.  Large  doses  of  strychnin,  or  strychnin  repeated  too  fre- 
quently, seem  to  interfere  \\'ith  normal  diastole  of  the  heart  and  prevent 
the  normal  filling  of  the  heart  cavities  and  therefore  the  normal  output 
of  the  heart  into  the  arteries.  Henderson  seems  to  have  shown  that 
such  cardiac  stimulants  cannot  increase  the  output  from  the  heart 
cavities. 

"6.  Digitalis  would  rarely  be  indicated,  if  ever,  in  acute  shock. 
The  greatest  advantage  of  digitalis  is  in  cardiac  dilatation,  and  its 
best  activity  is  in  cardiac  hj-pertrophy  with  dilatation." 

1  Jour.  Am.  Med.  Assn.,  August  7,  1909,  p.  461. 


CHAPTER   II 


PATHOLOGICAL  DENTITION 


Predisposing 


Causes 


Exciting 


Defective  embrj'onic  development. 

Perverted  development. 

Malnutrition. 

Syphilis. 

Rachitis. 

Neurotic  tendency. 

Other  diseased  conditions. 

Arrested  maxillarj-  development. 

Undue  thickening  and  resistance  of  over- 
Ij-ing  tissue,  causing  pressure  from 
crowns  of  teeth  to  react  through  the 
«open  ends  of  roots  upon  the  dental 
papilla,  thus  gi\'irg  direct  irritation. 

Malposition. 


Ix  considering  pathological  conditions  coincident  with  irritation 
manifested  during  the  period  of  tooth  eruption  in  infants,  it  should 
be  remembered  that  the  germs  of  the  first  teeth  begin  to  develop  as 
early  as  the  fifth  week  of  embryonic  life,  that  these  are  quickly  followed 
by  those  of  the  permanent  set,  and  that  at  birth  the  tooth  follicles  for 
both  sets  are  present  in  the  jaws  in  course  of  development. 

During  the  period  of  tooth  development  of  infants  a  high  mortality, 
the  prevalence  of  intestinal  disturbances,  skin  eruptions,  and  spas- 
modic and  other  nervous  affections  are  noted.  The  same  tendencies 
appear  at  later  periods,  notably  about  the  fifth,  sixth,  or  seventh  year, 
as  the  first  permanent  molars  appear,  and  again  when  the  second  and 
third  molars  are  endeavoring  to  erupt. 

Kiernan,  Talbot,  Kirk,  Upson,  and  others  have  called  attention  to 
the  fact  that  these  periods  of  stress  frequently  mark  the  time  of  the 
first  manifestations  of  chorea,  epilepsv,  and  other  neurotic  tendencies 
(p.  309). 

The  process  of  tooth  eruption  is  related  to  these  affections  by  direct 
irritation  through  pressure  caused  by  resistance  of  the  inflamed  or 
thickened  tissue,  covering  the  tooth  crown,  forcing  the  sharp  borders 
of  the  incompletely  developed  roots  against  the  pulp  tissue  with  its 
as  yet  unprotected  nerves  and  bloodvessels. 

Indirectly  this  irritation  tends  to  reduce  the  bodily  resistance  to 
bacteria,  disturbs  digestive  functions,  and  accentuates  inherent  ten- 
dencies to  neurotic  states  (Fig.  25),  now  recognized  as  vagotonia. 

All  too  frequently  patients  have  been  referred  to  the  author  with  a 
history  of  having  been  under  treatment  for  third  molars  that  were 
expected  to  erupt,  but  instead,  cancer  was  found  on  the  site  of  the 

(59) 


60 


PATHOLOGICAL  DENTITION 


inflamed  tissue  over  and  around  the  malposed  teeth  which  had  been 
allowed  to  progress  beyond  the  reasonable  hope  of  cure  because  of 
delay. 

Symptoms. — The  symptoms  are  local  and  general. 

Local  Symptoms. — Local  symptoms  are  readily  recognized  in  infant 
cases  by  the  evident  desire  of  the  child  to  bite  upon  any  substance  it  can 
put  into  its  mouth,  by  the  excessiAc  flow  of  saliva  incident  to  the 
unusual  irritation,  and  by  the  appearance  of  the  mucous  membrane 
sm-face  of  the  mouth  in  the  region  of  the  erupting  tooth  cro^^■ns,  where 
it  may  be  slightly  swollen,  red,  and  inflamed  in  appearance,  or  more 
often  white,  \\hen  the  gum  tissue  has  become  tightly  stretched  across 
the  incisal  or  occlusal  tooth  surfaces  and  toughened  until  unusually 
resistant. 


Fig    25. — Erupting  tooth. 

Occasionally  the  mouth  becomes  so  tender  that  the  infant  can 
with  difficulty  be  made  to  take  the  nipple  or  bottle,  and  the  character- 
istic stomatitis  affects  the  membrane  surface. 

With  adults,  the  local  manifestation  may  be  noted  in  the  appearance 
of  the  cusps  or  crowns  of  teeth  through  the  gum  upon  the  surface  of  the 
alveolar  ridges,  or  the  gmn  may  be  swollen  and  tender  from  being  bitten 
upon  by  the  antagonizing  tooth  in  the  opposite  jaw.  Spasmodic  con- 
traction of  the  muscles  of  mastication  may  result  from  direct  nerve 
irritation,  or  the  inflammation  may  extend  until  surrounding  muscles 


SYMPTOMS  61 

and  <]jlan(ls  are  involved,  and  cause  temporary  ankylosis,  the  degree 
of  which  may  be  slight,  or  sufficient  to  cause  complete  fixation  of  the 
mandible. 

The  swelling  may  be  confined  to  the  tissues  in  the  region  of  the  angle 
of  the  jaw,  or  include  the  parotid  and  submaxillary  structures  also. 
Pain  may  be  continuous  and  severe,  or  be  noticed  only  upon  attempt  to 
open  the  mouth.  The  tissues  of  the  floor  of  the  mouth  and  tongue 
may  become  infected  and  cause  symptoms  identical  with  Ludwig's 
angina,  and  thus  endanger  life  through  difficulty  in  respiration  and 
SAvallowing. 

General  Symptoms. — In  infant  cases  it  is  sometimes  practically  impos- 
sible to  differentiate  between  some  of  the  many  expressions  of  disease 
that  may  be  coincident  with  tooth  eruption  and  other  pathological 
affections  to  M'hich  such  infants  are  prone. 

Spasms,  infantile  paralysis,  disturbance  of  the  digestive  tract, 
diseases  of  the  skin  and  mucous  membrane,  trophic  changes,  meningitis, 
and  affections  of  the  spinal  cord  leading  to  muscular  atrophy,  etc., 
may  be  the  result  of  predisposition  engendered  by  direct  nerve  irrita- 
tion, infection,  or  weakened  resistance  incident  to  tooth  eruption; 
on  the  other  hand,  these  may  be  due  to  other  etiological  agencies, 
therefore  diagnosis  is  necessarily  made  by  exclusion. 

In  adult  cases  malposed  or  supernumerary  teeth  are  frequent  causes 
of  reflex  pain  (Fig.  2G,  and  p.  310)  and  of  other  disturbances  of  similar 
origin,  such  as  facial  spasm,  chorea,  epilepsy,  and  kindred  spasmodic 
affections,  paralysis,  sensory  alterations,  neuralgia,  or  trophic  changes, 
which  may  be  manifested  in  many  different  forms. 

Such  teeth  may  become  encysted  and  thus  occupy  the  central  posi- 
tion in  cysts  that  are  sometimes  of  enormous  size.  Many  serious 
pathological  states  may  result  from  irritation  and  infection  of  the 
tissues  surrounding  teeth  that  are  in  course  of  eruption,  especially  if 
impacted  or  in  malposition.  Long-continued  nasal  and  antral  diseases 
have  been  proved  to  be  due  to  malposed  teeth  in  these  situations. 
Blindness,  deafness,  tinnitus  aurium,  and  other  affections  indicating 
interferance  with  some  cranial  nerve  have  been  more  or  less  frequently 
reported  from  the  same  cause.  Local  infection  may  occur,  especially 
in  the  case  of  malposed  third  molars,  that  are  unable  to  erupt  and  have 
a  more  or  less  complete  covering  of  gum  tissue  remaining  upon  their 
crown  surfaces.  The  accumulation  of  bacteria-laden  secretions  and 
debris  is  thus  favored  by  the  pocket  which  is  formed  between  the  gum 
and  tooth  surface.  Aided  by  abrasion,  swelling  and  other  inflamma- 
tory symptoms  result,  which,  once  inaugurated  from  the  center  thus 
established,  may  readily  enter  the  IjTnphatic  pathways  of  the  neck  and 
lead  to  septicemia,  pyemia,  and  other  disorders  of  the  blood  and  lym- 
phatic systems.  The  final  result  may  be  grave  or  slight,  according  to 
the  resistance  of  the  individual  and  other  factors  upon  which  the 
prognosis  of  all  such  affections  must  depend.  Figs.  26  to  42  are 
examples  of  such  cases. 


62 


PATHOLOGICAL  DENTITION 


Diagnosis.— Infant  Cases.— Erupting  teeth  in  infant  mouths  are 
usually  easily  recognized  by  prominences  upon  the  alveolar  ridges 
and  the  appearance  of  the  gum  tissue  over  and  around  the  erupting 
tooth  crowns,  which  become  dark  and  slightly  swollen,  or  white  if 
reduced  to  a  toughened,  resistant  membrane. 

Adult  Cases. — \Yith  adults  the  diagnostic  guides  are:  (1)  Absence 
of  a  tooth  without  history  of  extraction  or  loss  from  other  known 
cause,  the  possibility  of  other  supernumerary  teeth  always  being 
borne  in  mind  in  this  connection.  (2)  Unusual  fulness  in  the  por- 
tion of  the  jaw  in  which  the  suspected  unerupted  tooth  may  lie.  (.3) 
Exploration  with  a  smooth,  sharp-pointed,  stiff  probe  passed  through 
the  gum  tissue  and  into  the  bone  structure,  which,  in  the  process  of 


Fig.  26. — Skull  ^\-ith  an  unerupted  cuspid  tooth  placed  in  the  same  situation  as  that 
in  which  it  was  found  in  the  mouth  of  a  man  who  suffered  for  many  years  with  tic 
douloureux. 


absorption  incident  to  tooth  eruption  or  during  the  effort  of  an  impacted 
tooth  to  erupt,  usually  becomes  more  or  less  porous,  and  thus  permits 
of  the  passage  of  the  probe  until  it  touches  the  hard,  smooth,  easily 
recognized  surface  of  the  tooth  crown.     (4)  The  a:-rays. 

In  the  third  molar  region  differentiation  must  be  made  to  exclude 
mumps,  submaxillary  or  parotid  inflammation  from  other  cause,  syphilis, 
ptj'alism,  tumors,  true  ankylosis,  and  other  infectious  diseases.  The 
presence  of  the  tooth  is  the  determining  factor,  and  the  .r-rays  the  final 
method  of  decision  when  other  diagnostic  efforts  fail. 

Treatment. — Treatment  of  Infants. — Give  direct  relief  by  cutting 
through  the  overlying  tissue  down  to  the  erupting  tooth  crown.  An 
attendant  should  hold  the  baby  firmly,  and  by  lowering  its  head  induce 
it  to  cry.     This  immediately  causes  the  mouth  to  be  opened,  so  that 


TREATMENT 


63 


there  is  little  difficulty  in  ^aininji;  access  to  the  alvTolar  ridges.     With  a 
sharp-i)()iiited  histoury  or  a  surgical  knife,  protected  l)y  being  wrapped 


Fig.  27. — Impacted  teeth  in  adult  case. 
Deciduous  teeth  crowned  through  error 
on  the  part  of  dentist.  Chronic  disease 
in  this  region  finally  led  to  diagnosis  with 
the  x-rays. 


Fig.  28. — Impacted  cuspid  in  adult 
case,  with  an  interesting  history  of 
neuralgic  pain. 


Fig.  29  Fig.  30 

Figs.  29  and  .30  show  two  impacted  lower  third^molars  in  the  jaw  of  a  girl,  aged  fifteen 

years,  who  suffered  great  pain  and  other  distressing  nervous  symptoms. 


Fig.  31. — Two  unerupted  cuspids  situated  in  the  palate  of  a  girl,  aged  twenty-two  years. 


with  gauze,  tape,  or  other  material,  the  point  alone  being  exposed, 
make  an  incision  longer  than  the  tooth  is  wide,  if  it  be  one  of  the  anterior 
teeth;  cut  down  upon  the  incisal  surface,  and  follow  it  entirely  across. 


64 


PATHOLOGICAL  DENTITION 


Fig.  32. — Radiogram  of  the  mouth  of  a  young  woman,  aged  twenty  years,  showing 
an  impacted  third  molar.  In  this  case  severe  neuralgic  pain  in  the  head  was  relieved  by 
removal  of  the  impacted  teeth. 


Fig. 


33. — Uncrupted  left  cuspid  near  the  orbit  in  the  case  of  a  man,  aged  twenty-six 
years.     Maxillary  sinus  on  left  side  involved. 


TREATMENT 


65 


Biciispifls  and  molars  require  crucial  incisions  long  enough  in  each 
direction  to  include  the  cusps  of  the  erupting  teeth  as  shown  in  Fig.  43. 


Fig.  .34. — Teetli  in  i-jurse  uf  eruption.    This  ilLustrates  the  difficulties  encountered  when 
teeth  are  crowded  in  the  jaws. 


Fig.  .3.5. — A  \dew  of  an  impacted  lower  third  molar.      (Cryer.) 

Occasionally  it  is  necessary  to  remove  the  entire  portion  of  gum 
which  covers  the  occlusal  surfaces  of  the  erupting  teeth. 
5 


66 


PATHOLOGICAL  DENTITION 


Treatment  of  Adults. — Fresenatiov  of  flir    Teeth. — When  malposed 
or  impacted  teeth  are  diagnosticated  with  the  aid  of  the  .r-ravs   or 


Fig.  oG. — All  uncoiiiinou  iiiipacted  lower  third  molar.      (Cryer.) 

otherwise,  it  should  be  remembered  that  they  need  not  necessarily 
be  condemned^  because,  unless  they  are  supernumerary  teeth,  each 


Fig.  37. — Showing  an  inverted  lower  third  molar  erupting  into  the  submaxillary  fossa. 

(Ottofy.) 

one  has  its  rightful  place  in  the  complement  of  the  perfect  individual. 
Usually  such  teeth  are  crowded  out  of  place  and  their  eruption  is  pre- 


TREATMENT 


67 


vented  by  insufficient  or  at  least  imperfect  development  of  the  jaws 
and  dental  arches.  The  proper  remedy,  therefore,  except  when  some 
unusual  circumstances  contra-indicate  such  treatment,  is  to  expand 
the  dental  arches  and  regulate  the  teeth  in  such  manner  as  to  give 
opportunity  for  the  imjjacted  tooth  or  teeth  to  erupt.  When  this  is 
done,  e\'en  ^^'ith  persons  of  quite  advanced  years,  and  the  eruption 


Fig.  38. — Showing  tooth  malposed  in  ramus  of  the  mandible.     (Cryer.) 

of  the  teeth  stimulated  by  methods  well  known  to  orthodontists,  such 
teeth,  unless  very  abnormally  situated,  can  usually  be  brought  into 
proper  position  quite  satisfactorily. 

Frequently  upper  third  molars  appear  to  erupt  with  their  crown 
surfaces  turned  toward  the  cheek  and  apparently  outside  of  the  line 
of  the  upper  dental  arch.     As  a  matter  of  fact,  it  is  the  arch  that  should 


Fig.  39. — Impacted  third  molar  below  the  second  molar.     (Cryer.) 


be  expanded  out  to  the  line  of  the  third  molars,  thus  giving  them  room 
to  erupt  in  correct  position.  This  at  the  same  time  restores  to  some 
extent  the  size  of  the  nares,  which  under  proper  examination  are  often 
found  contracted  and  otherwise  deformed.  Extraction  of  the  teeth, 
while  giving  apparent  relief,  usually  increases  instead  of  decreasing  the 
ill  effects. 


68 


PATHOLOGICAL  DENTITION 


Fig.  40. — An  impacted  upper  third  molar.     A  similar  condition  found  on  the  opf)Osite 
side  of  the  skull.     (Cryer.) 


Fig.  41. — Radiogram  showing  impacted  canine.     (Cryer.) 


TREATMENT 


69 


In  like  manner,  lower  third  molars  may  be  impacted,  with  the  usual 
tipping  forward  of  the  crown  with  its  occlusal  surface  turned  toward 
the  distal  side  of  the  second  molar.  Unless  too  firmly  locked  or  too 
solidly  embedded  in  the  angle  of  the  jaw  to  make  such  treatment 
practicable,  they  may  sometimes  be  A\edged  away  from  the  second 


Fig.  42. — Radiogram  of  mandible,  showing  rudimentary  fourth  molar.      (Cryer.) 

molar  sufficiently  to  free  the  mesial  line  angle  from  being  locked  under 
the  contoured  distal  surface  of  the  adjoining  tooth,  thus  enabling  it 
to  come  forward  and  upward  into  natural  position. 

The  author  does  not  urge  extreme  treatment  in  these  cases,  but  he 
has  abundant  clinical  reasons  for  believing  that  this  aspect  should 
always  be  considered  before  resortins  to  extraction. 


Fig.  43. — Lines  of  incision  in  lancing:  a,  over  the  molars;  b,  b,  over  the  canines  and 
incisors  before  eruption;  c,  c,  c,  over  the  molars  and  canines  after  partial  eruption.  (J.  W. 
White.)  Complete  removal  of  the  overlying  gum  tissue  by  an  incision  extending  com- 
pletely around  the  crown  of  the  tooth  is  often  required. 

In  adults  a  thick,  resistant,  bony  covering  sometimes  lies  between 
the  tooth  crown  and  the  surface,  which  for  some  reason  has  resisted 
absorption.  In  these  cases  it  is  always  beneficial  and  sometimes 
necessary  to  remove  this  bone  structure  with  a  surgical  or  dental 


70  ■  PATHOLOGICAL  DENTITION 

engine  burr,  so  that  eruption  of  the  tooth  may  be  facilitated,  and  that, 
if  necessary,  proper  attachments  be  made  to  the  crown  for  ortho- 
dontic purposes. 

Treatment  in  cases  of  supernumerary,  and  also  of  geminated  (twin) 
teeth  must  be  determined  by  consideration  of  the  cosmetic  results 
as  well  as  the  effect  upon  underlying  pathological  and  developmental 
conditions  which  may  be  influenced  by  extraction  or  retention.  The 
time  of  correction  is  often  an  important  factor  in  these  respects. 

Palliative  Treatment. — Patients  suffering  from  acute  inflammatory 
conditions,  due  to  erupting  teeth,  particularly  third  molars,  frequently 
come  for  treatment  in  a  state  of  great  distress  from  pain,  inability  to 
open  the  mouth,  and  associated  symptoms  of  local  disturbance,  together 
with  rise  in  temperature  and  other  general  indications  of  the  toxic 
influence  of  the  infection.  Although  it  may  be  apparent  that  the  offend- 
ing tooth  must  be  extracted,  the  decision  as  to  the  time  of  extraction  is 
a  matter  of  much  importance.  A  number  of  deaths  have  been  reported 
from  immediate  operation  upon  cases  during  the  acute  inflammatory 
stage,  and  the  presence  of  microorganisms  in  the  blood  appears  to  have 
demonstrated  that  the  opening  of  bloodvessels  incident  to  operation 
for  removal  of  the  impacted  teeth  has  allowed  the  direct  entrance  of 
septic  matter  into  the  circulation  and  converted  septic  intoxication 
into  true  septicemia.  The  wiser  plan  would  therefore  be  to  await  the 
subsidence  of  the  acute  symptoms  in  every  case  before  undertaking 
operation.  This,  however,  is  not  always  practicable,  because  the 
danger  involved  from  continued  progress  of  the  inflammation  and 
infection  may  absolutely  force  drastic  measures,  even  though  they  be 
adopted  with  full  knowledge  of  the  danger.  In  most  cases,  however, 
notwithstanding  the  usual  urging  of  the  patient  from  relief,  the  fixed 
jaw  can  be  gradually  opened  by  the  use  of  a  mouth  gag  with  or  without 
the  aid  of  an  anesthetic,  and  retained  in  at  least  a  partially  open 
position  by  the  use  of  rubber  corks,  as  indicated  under  treatment  of 
ankylosis  (Fig.  199,  p.  372).  With  the  mouth  thus  opened,  it  is  pos- 
sible to  reach  the  seat  of  the  inflammation,  to  draw  oft'  the  pus  from 
over  and  around  the  impacted  tooth  crown,  to  disinfect  the  mouth, 
and  to  make  local  applications,  both  intrabuccal  and  extrabuccal, 
for  the  relief  of  the  inflammation.  After  this,  extraction  of  the  tooth 
may  be  accomplished  with  greater  safety. 

REMOVAL  OF  IMPACTED  TEETH. 

When  unfavorable  conditions  which  contra-indicate  the  immediate 
removal  of  impacted  teeth  have  been  overcome,  or  in  the  unusual 
cases  which  require  operation  without  waiting  for  their  subsidence, 
and  when  orthodontic  methods  for  effecting  correct  eruption  are 
precluded  or  inadmissible,  the  removal  of  such  teeth  is  required. 

The  first  principle  in  the  removal  of  impacted  third  molars  and 
other  impacted  teeth  is  that  surrounding  bone  which  may  seriously 


REMOVAL  OF  IMPACTED  TEETH  71 

interfere  with  extraction  should  be  removed  before  unusually  forcible 
attempts  are  made  with  dental  forceps.  Unwise  use  of  these  instru- 
ments is  apt  to  result  in  failure  to  extract  the  tooth,  causing  much 
unnecessary  pain  and  discomfort  or  even  serious  injury  to  the  patient. 
The  crown  of  the  tooth  may  be  crushed  or  broken  off,  thereby  increas- 
ing the  difficulties  of  extraction;  pieces  of  bone  may  be  splintered  in 
such  manner  as  to  cause  necrosis,  or  the  jaw  bone  may  be  fractured, 
as  has  been  known  to  occur,  especially  when  the  so-called  Physick 
forcejis  have  been  used. 

The  Danger  of  Such  Operations. — On  account  of  the  anatomical 
situations  of  impacted  third  molars  and  other  teeth,  and  the  peculiar 
conditions  under  which  their  removal  must  be  effected,  the  following 
definite  dangers,  in  addition  to  those  common  to  other  surgical  opera- 
tive risks,  must  be  anticipated : 

1.  The  inspiration  of  blood.  When  the  patient  is  deeply  under 
a  general  anesthetic  and  lying  in  the  prone  position,  blood  may  easily 
be  drawn  into  the  trachea  in  such  quantities  as  to  fill  the  bronchi  and 
to  flood  the  lungs  sufficiently  to  cause  instant  death.  Fatalities 
during  mouth  operations  have  not  uncommonly  occurred  from  this 
cause. 

2.  The  inspiration  of  even  small  quantities  of  blood  with  bacteria- 
laden  saliva  may  lead  to  inspiration  pneumonia,  and  this  may  indi- 
rectly cause  a  fatal  termination. 

3.  The  immediate  loss  of  blood,  if  michecked,  may  be  a  serious 
menace  to  the  vitality  of  the  patient,  or  secondary  hemorrhage  may 
be  difficult  to  control  and  be  serious  in  its  results.  There  is  always 
also  the  danger  of  encountering  a  hemophiliac  even  when  neither  the 
pathognomonic  swelling  of  the  joints  or  the  family  history  may  be 
sufficiently  indicative  to  serve  as  a  warning.  The  dangers  and  diffi- 
culties attendant  upon  the  management  of  a  bleeder  with  wounds  of 
this  character  in  the  mouth  need  hardly  be  elaborated. 

4.  The  danger  of  general  infection,  which  has  been  already  referred 
to. 

5.  The  danger  of  fracturing  the  jaw  or  causing  temporary  or  per- 
manent ankylosis  or  injuries  to  the  nerves,  that  may  leave  serious 
postoperative  effects. 

6.  Accidental  failure  to  secure  the  tooth  when  forced  out  into  the 
mouth,  through  which  it  may  be  swallowed  or  become  lodged  in  the 
trachea  or  bronchi,  causing  suffocation  and  death.  A  number  of  such 
cases  have  been  reported. 

List  of  Serious  Accidents  of  Extraction. — The  following  list  of  serious 
accidents  of  extraction,  compiled  by  Dr.  Julius  Endelman,  of  Phila- 
delphia, from  the  Dental  Cosmos,  up  to  and  including  1904,  and 
reported  at  the  Fourth  International  Dental  Congress,  at  St.  Louis, 
gives  an  indication  of  the  possibilities  of  these  dangers.  ^Miile  by  no 
means  complete  and  not  including  accidents  since  that  date,  it  is 
nevertheless  sufficient  to  call  attention  to  the  frequency  and  the 


72  PATHOLOGICAL  DENTITION 

nature  and  character  of  the  most  common  of  such  accidents,  as  well  as 
to  the  danger  which  attends  them. 

Removal  of  the  floor  of  the  antrum,  2;  contraction  of  the  muscles 
of  the  forearm  and  flexors  of  the  fingers  and  adduction  of  thumbs, 
1;  tooth  impacted  in  bronchus,  death,  1;  swallowing  of  tooth,  1;  swal- 
lowing of  a  tooth,  recovery,  1;  fracture  of  maxillse,  2;  shock  following 
extraction,  death,  1 ;  taking  cold  after  extraction,  infection,  1 ;  migra- 
tion of  stump,  1 ;  removal  of  tuberosity,  1 ;  tooth  in  bronchus,  recovery, 
4;  choked  by  tooth,  death,  1 ;  pneumonia  caused  by  a  tooth  in  bronchus, 
1 ;  paralysis  after  extraction,  4 ;  dislocation  of  mandible,  1 ;  suffocation 
by  swallowing  of  a  tooth  during  extraction,  1 ;  third  molar  driven  into 
jaw  during  extraction,  1 ;  fracture  of  palatine  bone,  1 ;  purulent  infec- 
tion after  extraction,  1;  purulent  infection  following  fracture  of  jaw 
during  extraction,  1 ;  broken  piece  of  forceps  left  in  jaw  after  extraction, 
infection,  1 ;  death  after  extraction,  infection,  3 ;  tooth  slipped  from 
forceps  into  trachea,  1 ;  forcing  tooth  into  antrum,  1 ;  hemorrhage, 
death,  1. 

"Out  of  the  total  of  35  cases,  8  terminated  fatally;  3  of  the  fatal 
cases  were  the  result  of  infection  directly  traceable  to  foul  instru- 
ments. 

"  There  have  probably  been  many  similar  accidents  not  reported,  but 
cases  of  serious  infection  following  extraction  and  death  from  this  cause 
in  a  considerable  number  have  undoubtedly  not  been  reported." 

Anesthetics. — ^In  many  of  the  less  serious  cases  the  injection  of  a 
local  anesthetic  seems  to  be  sufficient.  The  author,  however,  fears 
local  anesthesia  chiefly  because  of  the  danger  of  carrying  infection  into 
the  tissues  and  because  the  large  quantity  of  the  anesthetic  required 
for  the  removal  of  deeply  embedded  teeth  has  often  caused  local  necro- 
sis and  serious  general  effects.  A  marked  instance  of  this  occurred  in 
an  individual  for  whom  an  impacted  third  molar  was  removed  under 
local  anesthesia  induced  by  the  use  of  cocain  and  adrenalin  injected 
by  a  high  power  syringe.  Some  hours  after  the  operation  loss  of 
consciousness  and  paralysis  ensued,  with  complete  destruction  of  the 
usefulness  of  the  life  of  the  patient,  presumably  through  an  embolus 
forced  into  the  brain. 

Conductive  anesthesia  by  blocking  the  nerve  supply  with  novocain 
as  described  on  page  20  and  illustrated  in  the  section  on  Anesthesia 
gives  satisfactory  results. 

In  this  way  not  only  is  freedom  from  pain  assured,  but  the  adrenalin, 
or  suprarennin  effect,  is  shown  in  marked  lessening  of  the  hemorrhage. 

This  facilitates  both  rapidity  and  accuracy  in  the  performance  of 
the  operation. 

When  a  general  anesthetic  is  used,  whether  nitrous  oxide  gas,  nitrous 
oxide  gas  and  oxygen,  somnoform,  or  ether,  the  operator  should  make 
certain  that  the  anesthesia  will  continue  sufficiently  long  to  permit 
a  complete  operation  without  undue  haste,  and  without  the  disadvan- 
tages attending  such  operations  under  imperfect  anesthesia.     Neglect 


REMOVAL  OF  IMPACTED  TEETH 


73 


of  this  has  caused  inaii}^  accidents  which  might  have  been  avoided  had 
anesthetic  conditions  been  more  fa\'oral)le. 


Fig.  44. — Impacted  lower  third  molar,  with  overlying  bone  removed  to  facilitate 

extraction. 

Asepsis. — Surgical  cleanhness  should  be  rigidly  enforced  and  every 
effort  made  to  avoid  infection.     Whenever  possible,  the  teeth  should 


Fig.  45. — ^This  shows  the  method  of  controlling  the  field  of  operation  in  extraction  of 
impacted  lower  teeth.  Gauze  held  between  tongue  and  jaw,  retractors  and  mouth  gag 
in  place,  and  the  surface  of  the  impacted  lower  third  molar  exposed  ready  for  extraction. 


be  thoroughly  cleaned.     The  mucous  membrane  surfaces  of  the  tongue, 
cheeks,  lips,  and  the  surfaces  of  the  tooth  crowns  should  be  thoroughly 


74 


PATHOLOGICAL  DENTITION 


cleansed  with  alcohol  and  the  immediate  field  of  operation  painted  with 
iodine.  Neglect  or  carelessness  in  these  respects  may  cause  great 
suffering  to  the  patient  or  even  death. 


Fig.  46. — Another  form  of  impacted  lower  third  molar,  exposed  and  ready  for  removal. 

Position  of  the  Patient. — As  a  safeguard  against  the  inspiration  of 
blood,  the  patient,  if  lying  in  a  prone  position,  should  have  the  shoul- 
ders raised  sufficiently  to  tip  the  head  backward.  When  the  face  is 
turned  to  one  side  the  blood  and  mucus  will  then  tend  to  flow  into  the 
side  and  posterior  portion  of  the  pharynx.     In  this  situation  quick 


Fig.  47. — Method  of  exposing  an  impacted  upper  third  molar  for  extraction. 

sponging  is  made  possible  and  the  likelihood  of  passage  into  the  trachea 
is  decreased.  In  this  position  also  a  tube  may  be  passed  through  the 
nose  down  to  a  point  opposite  the  tracheal  opening  through  which  the 
anesthetic  may  be  administered  and  the  pharynx  packed  with  gauze. 


REMOVAL  OF  IMPACTED  TEETH 


75 


This  procedure,  while  objectionable  in  some  respects,  is  effective  in 
prc\  cntinji;  the  escape  of  blood  and  mucus  or  the  tooth  in  this  direction. 


Fig.   is. ^-Method  of  exposing  an  impacted  upper  cuspid  on  the  palate  surface. 

Control  of  the  Field  of  Operation. — The  entire  field  of  operation 

may  be  brought  into  view  and  the  operation  greatly  facilitated  by 
drawing  back  the  corner  of  the  mouth  and  cheek  with  a  retractor  and 


Fig.  49. — Method  of  exposing  a  malposed  and  impacted  upper  cuspid  from  the  labial 

side  of  the  jaw. 

holding  the  tongue  out  of  the  way  by  a  roll  of  gauze  grasped  in  a 
forceps.  The  latter  also  serves  to  prevent  the  blood  from  flowing 
into  the  pharynx  (Fig.  45). 


76  PATHOLOGICAL  DENTITION 

Exposure  of  the  Embedded  Tooth  Crown. — The  tooth  crown  with 
its  embedded  root  should  be  exposed  (Figs.  44  to  49)  sufficiently  to 
allow  it  to  be  firmly  grasped  by  the  forceps  or  raised  with  an  elevator. 
When  this  method  is  followed,  it  usually  renders  the  use  of  the  so- 
called  Physick  forceps  unnecessary,  and  thus  tends  to  avoid  the 
danger  of  unnecessary  fracture  of  the  alveolar  process  or  jaw. 

This  is  best  accomplished  by  the  remo\'al  of  the  overlying  and 
surrounding  bone  structure  with  surgical  or  dental  engine  burs.  When 
a  dental  engine  is  used,  the  burs  made  for  bone  cutting  or  those  used 
for  finishing  vulcanite  plates  or  root  canal  reamers  are  best  adapted 
for  this  purpose,  because  the  flanges  are  more  open  and  will  cut  fresh 
bone  better  than  those  intended  for  cutting  dentin  or  enamel,  which 
quickly  clog  and  become  useless. 

WOUNDS  OF  THE  MOUTH. 

General  Consideration  of  Wounds. — Definition. — A  wound  is  a 
solution  of  the  continuity  of  the  tissues  of  the  body  caused  by  some 
external  agent.  Solutions  of  the  tissues  of  the  body  resulting  from 
disease  are  not  classed  as  wounds.  In  surgery  it  is  generally  under- 
stood that  skin  or  mucous  membrane  must  be  involved.  In  medical 
jurisprudence  any  lesion  of  the  body  resulting  from  external  violence 
is  so  classed,  thus  giving  much  wider  range  in  application  than  when 
the  term  is  used  in  surgery. 

Varieties. — Wounds  are  classified  as  follows:  Incised,  cut  with  a 
sharp  instrument;  lyundured,  cut  with  a  pointed  instrument;  lacerated, 
torn;  contused,  bruised;  gunshot,  made  by  a  projectile;  poisoned, 
caused  by  toxic  substances  introduced  into  the  tissues  of  the  body,  as 
from  the  bite  of  a  venomous  snake,  insect,  rabid  dog,  or  from  dissecting 
wounds. 

These  may  be  considered  under  one  general  division:  Aseptic,  free 
from  infection  by  microorganisms;  sejjtic,  infected  by  the  micro- 
organisms of  fermentation  or  putrefaction. 

They  may  be  again  subdivided  for  the  purpose  of  description  into 
superficial,  aft'ecting  the  skin  or  mucous  membrane  only;  deep,  involv- 
ing the  underlying  tissues;  simple,  without  complication;  complicated, 
when  there  is  any  complication  in  addition  to  the  wound,  as  from  a 
foreign  body  or  substance,  serious  infection,  unusual  hemorrhage,  or 
injury  to  large  nerves,  bone,  vessels,  or  other  important  structures; 
surgical  wound,  when  made  in  the  performance  of  a  surgical  operation; 
flesh  wounds,  involving  only  soft  tissues;  subcutaneous,  beneath  the 
skin;  and  open  or  closed. 

Repair  of  Wounds. — Healing  by  Immediate  Union. — When  the  lips 
of  a  clean  incised  wound  are  brought  together  at  once  and  kept  in 
close  approximation,  rapid  healing  occurs.  In  this  case  a  microscopic 
examination  shows  slight  exudation  from  the  sm-face  of  the  wound 
and  proliferated  connective-tissue  cells.     The  epithelial  continuity 


WOUNDS  OF  THE  MOUTH  77 

is  restored  by  proliferation  of  the  epithelial  cells.  This  is  called  healing 
by  immediate  union. 

Healing  by  First  Intention. — When  apposition  of  the  wound  surface 
is  less  accurate,  the  amount  of  exudation  is  greater.  Twenty-four 
hours  after  injury  the  parts  are  red  and  swollen,  but  soon  become 
glazed  in  appearance.  The  process  is  much  the  same  as  in  immediate 
union,  except  that  the  amount  of  exudation  is  greater  and  the  healing 
process  is  slower.    This  is  called  healing  by  first  intention. 

Healing  by  Second  Intention,  or  Healing  by  Granulation. — Retention 
by  or  of  foreign  bodies  or  continued  exposure  causes  small  red  elevations, 
called  granulations,  to  appear  upon  the  surface  of  the  wound  within 
two  or  three  days  after  injury.  These  granulations  are  newly  formed 
capillaries  covered  by  round  cells,  and  later  on  giant  cells  occasionally 
appear.  If  the  wound  is  infected  and  pus  appears,  the  proliferated 
round  cells  gradually  elongate  to  form  new  fibrous  tissue,  which 
ultimately  contracts  to  form  cicatrices  or  scars.  Epithelial  continuity 
is  brought  about  by  multiplication  of  epithelial  cells  at  the  surface  of 
the  wound. 

Healing  by  Third  Intention,  or  Adhesions  by  Granulation  Surface. — 
Some  authors  use  this  term  to  signify  the  process  which  takes  place 
when  large  surfaces  are  required  to  be  filled  in  by  granulations,  in 
order  to  complete  the  healing  process,  as  the  cavities  of  large  abscesses, 
and  large  exposed  surfaces  which  sometimes  require  months  to  fill  in. 
As  there  is  no  essential  difference  from  the  healing  by  second  intention, 
except  in  degree,  it  seems  hardly  necessary  to  consider  it  as  a  special 
form  of  healing  process. 

Treatment  of  Wounds  of  the  Mouth. — The  steps  in  treatment  of 
wounds  in  this,  as  in  other  regions,  are  as  follows: 

1.  Prevention  or  correction  of  septic  conditions. 

2.  Control  of  hemorrhage. 

The  order  of  importance  of  these  two  procedures  is  necessarily 
interchangeable,  because  with  accident  or  injury  to  large  vessels  the 
first  consideration  would  obviously  be  arrest  of  hemorrhage  regardless 
of  sepsis.  In  the  absence  of  dangerous  flow  of  blood,  septic  consider- 
ations would  naturally  be  first. 

3.  Coaptation  of  the  Wound  Snrfaces  to  Promote  Healing. — Wounds 
of  the  mouth  involving  maxillary  bone  structures  do  not  often  permit 
exact  approximation  of  the  overlying  soft  tissues.  Incisions  or  injuries 
affecting  the  cheeks  and  lips  require  the  greatest  possible  care.  Not 
only  must  the  deeper  tissues  and  the  mucous  membrane,  as  well  as 
skin  surfaces,  be  brought  into  direct  contact  to  facilitate  union,  but 
reunion  of  divided  muscles  necessitates  skilful  adjustment  to  secure 
correct  muscular  action  after  the  healing  process  has  been  completed, 
and  to  give  freedom  from  the  contraction  of  scar  tissue,  which  causes 
deformity  when  the  parts  are  at  rest,  and  in  even  greater  degree  during 
muscular  action. 

4.  Dressings  if  required. 


78  PATHOLOGICAL  DENTITION 

5.  Prevention  of  Undue  Physiological  Action. — ^The  prevention  of 
tension  and  provision  for  physiological  rest  are  matters  of  great 
importance  and  often  of  considerable  difficulty.  Sutures  and  dressings 
intended  to  overcome  this  strain  upon  the  wound  surfaces  must  be  of 
such  character  as  to  hold  securely  until  a  period  of  time  has  elapsed 
sufficient  to  enable  the  muscular  fibers  to  become  securely  united. 

6.  Drainage  is  sometimes  required,  but  rubber  or  glass  tubes  and 
other  methods  employed  to  prevent  the  collection  of  fluid  in  deep 
wounds  of  other  parts  of  the  body  are,  as  a  rule,  impracticable  to  use 
in  the  mouth.  The  capillary  drainage  of  gauze  packing  is  the  correct 
procedure. 

Dressing. — Dressings  in  the  buccal  cavity,  as  dressings  in  other 
parts,  should  give  protection  against  external  pathogenic  bacteria, 
permit  the  healing  process,  and  prevent  the  collection  of  pus  or  other 
fluids  which  tend  to  delay  the  process  of  repair.  In  addition  they 
should  have  antiseptic  properties  to  combat  the  pyogenic  and  other 
microorganisms  constantly  present  in  the  oral  secretions.  The  danger 
of  swallowing  germicidal  agents,  however,  necessitates  a  weaker 
strength  than  would  otherwise  be  advisable.  The  almost  unavoidable 
further  weakening  by  solution  with  the  salivary  secretions  renders  it 
exceedingly  difficult  to  find  an  agent  capable  of  maintaining  its  own 
integrity  under  these  conditions  for  a  sufficient  length  of  time. 

The  author's  rule  is  to  leave  shallow  cavities  and  open  surfaces  in 
the  mouth  uncovered  and  to  depend  upon  frequent  cleansing  with 
mild  antiseptic  solutions  for  the  prevention  of  serious  infection  and  to 
promote  granulation.  In  deep  inaccessible  or  unfavorably  situated 
cavities  in  bone,  which  of  necessity  cannot  drain  themselves  properly, 
packing  with  sterile  gauze  WTung  out  in  acetozone,  or  some  antiseptic 
solution,  such  as  compound  tincture  of  benzoin,  or  1  to  10,000 
bichloride  of  mercury,  and  sealed  with  a  solution  of  gutta-percha  and 
chloroform,  or  collodion,  is  required.  The  gauze  should  not  be  allowed 
to  remain  more  than  twenty-four  hours,  because  of  the  bacteria-laden 
secretions  which  are  necessarily  absorbed.  Wounds  upon  the  buccal 
surfaces  of  the  lips  and  cheeks  which  permit  of  coaptation  can  be  well 
protected  by  careful  suturing  of  the  mucous  membrane  with  fine  gut 
sutures. 

In  the  treatment  of  all  wounds  the  first  consideration  should  be 
directed  to  the  cause.  Poisoned  wounds  of  all  varieties  necessarily 
require,  in  addition  to  local  treatment,  an  eft'ort  to  prevent  the  intro- 
duction of  the  poison  into  the  general  circulation,  and  in  this  way  to 
limit  its  effect.  Beyond  this  there  must  still  be  general  treatment  to 
enable  the  system  to  overcome  and  throw  oft"  the  effect  of  the  poison. 
The  bite  of  a  dog,  for  example,  should,  if  possible,  be  cauterized 
immediately.  If  rabies  is  suspected,  the  Pasteur  treatment  should  be 
given  in  addition.  Ordinarily  the  only  danger  from  bites  of  animals 
is  infection  from  the  mouth  secretions,  which  are  sometimes  highly 
toxic,  especially  if  carrion  has  recently  been  eaten.     The  bites  of 


WOUNDS  OF  THE  MOUTH  79 

poisonous  serpents  arc  more  apt  to  occur  at  the  extremities,  and  may 
sometimes  be  controlled  by  ligatures  tied  above,  to  close  the  portals 
of  the  general  circulation.  Free  blood-letting  in  wounds  of  this  char- 
acter and  the  removal  of  a  considerable  portion  of  tissue  in  the  immedi- 
ate vicinity  of  the  wound,  with  suction  to  draw  out  the  poison,  are 
sometimes  advantageous  methods  of  protection  against  the  general 
poisonous  effect.  Hypodermic  injections  of  strychnin  and  antitoxin 
prepared  in  the  usual  manner  from  the  poison  of  these  serpents  are 
believed  to  be  efficacious.  General  s;sTiiptoms  are  intense  localized 
irritation,  followed  by  marked  swelling,  usually  accompanied,  if 
progress  be  unchecked,  with  marked  symptoms  of  nausea,  vomiting, 
rapid  or  feeble  pulse,  mental  disturbance,  and  death. 

In  the  one  case  of  a  rattlesnake  bite  that  has  come  under  the  author's 
obser^'ation,  the  arm  of  the  hand  that  was  bitten  swelled  to  several 
times  its  natural  size  and  became  quite  black.  There  was  marked 
spasmodic  muscular  twitching  over  the  whole  body,  almost  to  the  point 
of  convulsions,  and  delirium  which  lasted  several  hours,  after  which 
there  was  slow  recovery. 

Wounds  received  in  making  dissections  lead  to  septicemia,  which 
will  be  considered  under  that  heading.  In  gunshot  wounds  and 
accidental  injuries  received  from  fireworks  there  is  marked  tendency 
to  tetanus.  Unless  the  bullet  be  favorably  situated  for  removal,  or  in 
contact  with  some  vital  part  which  makes  its  immediate  extraction 
imperative,  it  is  not  well  to  probe  too  much  in  an  effort  to  locate  it. 
Good  care  should  be  used  in  thoroughly  cleansing  a  wound  made  by  a 
projectile,  whether  it  be  a  bullet  or  some  other  substance  driven  into 
the  tissues  of  the  body  by  an  explosive  force,  because  there  is  always 
the  danger  of  infection  from  the  skin  surfaces,  or  from  particles  of 
clothing,  fractured  pieces  of  bone,  or  teeth  driven  into  the  wound. 
Aside  from  this  consideration  the  care  is  practically  like  that  of  any 
other  traumatic  lesion. 

All  experiences  in  the  treatment  of  wounds  of  many  kinds  since  the 
beginning  of  the  war  in  1914,  and  particularly  the  vast  number  of 
mouth,  jaw,  and  face  injuries  from  projectiles  of  every  description 
complicated  as  these  have  been  by  infections,  tetanus,  gas  bacilli, 
and  other  complications  which  have  been  favored  by  the  situations 
and  conditions  of  warfare  render  it  necessary  to  give  more  detailed 
consideration  to  the  treatment  of  wounds  of  the  mouth  in  Chapter  XIV, 
devoted  to  this  subject. 

Treatment  of  Hemorrhage  from  Wounds  of  the  Mouth. — There  are 
some  special  considerations  pertaining  to  the  treatment  of  hemor- 
rhage following  operations  upon  the  tissues  of  the  mouth  and  jaws, 
which,  notwithstanding  the  fact  that  they  are  necessarily  frequently 
referred  to  in  the  description  of  surgical  operative  procedures,  require 
distinct  recognition  in  this  connection. 

1.  Preceding  operations  of  serious  character,  the  coagulation  time 
of  the  blood  should  be  taken. 


80  PATHOLOGICAL  DENTITION 

2.  As  a  matter  of  postoperative  precaution  during  the  period  of 
unconsciousness  following  the  administration  of  a  general  anesthetic, 
the  patient's  head  should  be  kept  turned  upon  one  side,  so  that  the 
blood,  if  any,  will  flow  out  of  the  mouth,  where  it  will  be  observed  and 
not  be  likely  to  be  inspired. 

3.  When  wounds  of  the  mouth  give  evidence  of  excessive  flow  of 
blood  from  a  vessel,  or  of  capillary  oozing  with  tendency  to  persist, 
whether  the  operation  that  has  been  performed  be  the  extraction  of  a 
tooth  or  other  minor  procedure,  or  a  major  operation  involving  division 
of  tissue  over  a  large  area,  the  bleeding  should,  if  possible,  be  checked 
immediately  at  the  time  of  operation.  Too  often  dentists  or  physicians 
and  surgeons  are  inclined  to  underestimate  the  serious  possibilities 
of  the  flow  of,  blood  from  these  slight  wounds.  Patients  are  allowed  to 
leave  the  operating  room  or  even  go  home  with  blood  still  flowing  in 
more  or  less  considerable  quantity,  the  operator  carelessly  trusting 
to  the  cessation  of  hemorrhage  in  natural  course,  as  he  has  usually 
known  it  to  occur.  Sometimes  such  hemorrhages  are  allowed  to  become 
matters  of  vital  menace  before  hemostatic  measures  are  instituted.  It 
is  sometimes  difficult  to  pick  up  and  ligate  small  vessels  in  unfavorable 
situations  in  the  mouth,  but  it  is  an  exceedingly  simple  procedure 
to  carry  a  good  suture  in  a  small  curved  needle  around  the  point  of 
hemorrhage  and  to  tie  it  with  sufficient  pressure  to  check  the  flow  of 
blood.  The  small  portion  of  tissue,  other  than  the  vessel  itself,  which 
may  be  included  in  the  ligature  is  not  important.  Dentists,  particularly 
would  save  themselves  and  their  patients  trouble  by  the  habitual  use 
of  this  simple  procedure.  All  incisions  in  the  mouth  in  surgical  opera- 
tions should  be  made  so  far  as  practicable  of  such  form  and  in  such 
situations  that  blood  may  be  checked  either  by  ligation  or  packing 
of  the  wound.  This  can  nearly  always  be  accomplished,  and  the 
principal  dangers  of  postoperative  hemorrhage  thus  avoided.  Ligation 
or  compression  of  the  external  carotid  is  an  important  emergency 
procedure  to  prevent  uncontrollable  or  dangerous  loss  of  blood  in 
certain  grave  operations,  and  compression  of  the  vessels  of  the  extremi- 
ties by  rubber  bands  at  the  shoulders  and  hips  is  one  of  the  measures 
sometimes  adopted  to  reduce  the  activity  of  blood  flow  in  mouth  and 
head  operations. 

The  author  has  but  little  faith  in  the  use  of  local  astringent  appli- 
cations, and  believes  it  is  safe  to  assume  that  hemorrhage  is  under 
control  only  when  it  is  positively  checked  by  ligature,  packing,  or 
natural  coagulation  and  vascular  contraction.  The  local  application 
of  adrenalin  directly  or  as  a  spray  is  useful  in  slight  capillary  hemor- 
rhage. 

When  a  tooth  has  been  extracted,  it  is  usually  practicable  to  pack 
the  socket  with  gauze,  but  sometimes  the  gushing  of  blood,  even 
under  these  circumstances,  is  so  great  as  to  force  the  packing  out.  In 
these  cases  a  packing  much  larger  than  is  necessary  to  fill  the  tooth 
socket  must  be  used,  and  the  surplus  packing  arranged  above  the 


WOUNDS  OF  THE  MOUTH  81 

alveolar  ridge  in  such  manner  that  the  jaws  can  be  bound  together  and 
sufficient  pressure  exerted  to  overcome  that  of  the  blood.  Cases  have 
been  reported  of  dangerous  hemorrhage  where  several  teeth  have  been 
simultaneously  extracted,  particularly  when  the  outlines  of  the  tooth 
sockets  ha\^e  been  destroyed  by  the  removal  of  portions  of  the  sur- 
rounding alveolar  processes  incident  to  the  extraction  of  badly  decayed 
roots;  and  in  these  cases  it  is  often  impossible  to  locate  a  particular 
vessel  as  being  the  cause  of  the  flow  of  blood,  and  packing,  except  in  a 
general  way,  is  also  impracticable. 

Under  these  circumstances  a  simple  method  sometimes  resorted 
to  by  dentists  where  strictly  surgical  methods  have  failed  is  to  fill  an 
impression  cup  with  plaster  of  Paris,  placing  this  in  the  mouth  as  if  to 
take  an  impression,  but  allowing  it  to  remain  in  situ  and  binding  the  jaws 
firmly  against  it.  When  it  becomes  evident  that  a  patient's  blood  does 
not  have  the  normal  property  of  coagulation,  whether  this  be  due  to 
hemophilia  or  to  some  temporary  pathological  state  affecting  the  blood, 
treatment  must  be  instituted  to  arrest  the  hemorrhage.  (For  further 
description  see  page  40.) 


CHAPTER   III. 
INFECTIOUS  DISEASES. 

A  BETTER  understanding  of  toxicogenic  and  pathogenic  micro- 
organisms and  the  chemical  substances  which  they  elaborate,  as  well 
as  the  laws  governing  the  action  of  body  tissues  and  organs  when 
subject  to  morbid  conditions,  has  led  to  the  belief  that  many  terms  in 
their  strict  sense  are  misleading  or  incompatible  with  our  present 
knowledge  of  bacteriology  and  pathology.  It  has  also  shown  the  need 
of  avoiding  expressions  which  imply  distinction  between  forms  of 
disease  that  are  rarely  applicable  to  actual  clinical  conditions.  The 
wide  differences  of  opinion  expressed  by  eminent  WTiters  on  patholog}', 
surgery,  physical  diagnosis,  and  clinical  medicine,  with  regard  to  the 
application  and 'meaning  of  the  terms  sapremia,  septicemia,  toxemia, 
septic  intoxication,  pyemia,  etc.,  warrants  a  few  simple  definitions 
even  at  the  risk  of  appearing  to  be  too  elementary,  in  order  that  the 
author's  conception  of  correct  classification  may  be  clearly  understood. 

Definitions  and  Nomenclature. — Septic  intoxication  is  the  absorption 
of  toxic  products  with  resulting  general  spnptoms  of  disease  without 
entrance  of  the  infecting  microbe  into  the  blood  ciurent  (Keen). 

Infection  is  a  condition  produced  by  the  entrance  and  grovslh  within 
the  body  of  pyogenic  microorganisms  (Pearce,  Osier). 

Poisons.- — This  term,  when  given  broad  application,  signifies  any 
substance  injected  or  developed  within  the  body  which  causes  disease 
(Smith,  Keen). 

Distinction  is  made  between  true  toxin,  a  special  ferment  charac- 
teristic of  certain  bacteria,  and  protein  poison,  the  intracellular  toxin 
that  is  caused  by  bacterial  destruction  when  the  sensitized  body  cells, 
by  the  special  ferment  thus  formed,  break  do'^n  the  bacterial  cells. 
Protein  poison  is  produced  by  destruction  of  bacterial  proteins. 

Toxemia. — A  condition  of  the  blood  in  which  it  contains  poisonous 
products,  either  those  produced  by  the  body  cells  and  not  properly 
eliminated  or  those  due  to  the  growth  of  microorganisms  (Gould). 

Sapremia  (Putrid  Intoxication). ^According  to  derivation  and 
older  application,  sapremia  was  intended  to  describe  a  result  of  the 
bacteria  of  putrefaction.  Among  recent  ^Titers,  both  Johnston  and 
Brewer  accept  its  meaning  in  that  light.  Johnston  says,  "It  is  a  con- 
dition caused  by  the  absorption  into  the  system  of  the  saprophytic 
bacteria,"  but  admits  that  poison  solely  due  to  the  saproph;^'tes  or 
bacteria  of  putrefaction  without  toxemia  from  pus  microorganisms  does 
not  often  occur  even  with  gangrenous  conditions.  Stengel  expresses 
(82) 


INFECTIOUS  DISEASES  83 

the  more  general  sense  in  which  sapremia  has  become  understood 
when  he  says  it  is  a  condition  that  results  from  the  absorption  into  the 
general  circulation  of  toxic  products  from  local  suppurati\c  foci. 

Septicemia  is  the  descriptive  term  applied  when  the  infecting 
bacterium  itself  enters  the  blood  current  without  giving  rise  to  any 
secondary  collection  of  pus.  Anders  defines  septicemia  as  "A  disease 
due  to  the  introduction  into  the  system  of  the  products  of  putrefaction 
(sapremia)  or  to  microbic  invasion  of  the  blood  and  tissues  (true  septi- . 
cemia),  with  or  without  the  presence  of  a  local  seat  of  infection." 
Pyemia  signifies  that  microorganisms  have  been  carried  through  the 
circulatory  channels  and  that  infective  emboli  have  formed  new  foci 
of  inflammation  with  resulting  metastatic  abscess.  "Septicemia  plus 
metastatic  abscesses." 

Pearce^  calls  attention  to  the  confused  state  of  the  nomenclature 
of  these  aflections,  and  suggests  the  use  of  the  word  "toxemia,"  the 
meaning  of  which  he  would  circumscribe  as  follows:  "Under  the  term 
may  be  included  all  intoxications  due  to  the  absorption  of  bacterial 
poisons.  For  convenience  of  description  two  subdivisions  may  be  made : 
(1)  The  toxemias  associated  with  affections  demanding  surgical  inter- 
vention— the  so-called  '  sapremia ;'  and  (2)  those  of  the  acute  infectious 
diseases,  such  as  diphtheria,  typhoid  fever,  and  pneumonia." 

Smith  specifically  urges  the  abolishment  of  the  term  sapremia  and 
other  indefinite  or  inaccurate  expressions,  and  also  brings  forward 
the  word  toxemia  as  a  suitable  substitute;  but  he  desires  to  limit  it 
even  more  strictly  than  Pearce,  and  claims  that  it  should  only  be 
intended  to  "apply  to  the  diseases  in  which  one  or  more  poisons  are 
present  in  the  blood  which  are  not  of  parasitic  production,  while  septi- 
cemia should  be  applied  to  diseases  which  present  poisons  in  the  blood 
that  are  of  parasitic  origin,  the  parasite  itself  being  in  the  blood."^ 

Bacteriemia  (the  presence  of  schizomycetes  in  the  blood)  has  come 
to  be  quite  generally  used  in  the  effort  to  avoid  technical  confusion. 

Notwithstanding  these  differences  of  opinion  among  authorities, 
when  judged  from  a  surgical  point  of  view  the  essential  distinction 
resolves  itself  into  the  simple  question  as  to  whether  the  cause  of  the 
S}Tnptoms  of  disease  is  non-septic  or  septic  in  character.  It  appears 
to  the  author,  after  a  careful  review  of  the  opinions  of  the  writers 
whose  definitions  have  been  given,  and  many  others  that  could  not  be 
included,  that  toxemia,  according  to  the  definition  given  by  Pearce,  is 
in  some  degree  a  better  and  less  confusing  term  than  sapremia,  which 
has  been  so  variously  applied.  According  to  this,  our  division  of  the 
subject  would  then  be  toxemia,  septicemia,  and  pyemia.  That  these 
conditions  may  be  coincident  or  may  follow  each  other  without  the 
possibility  of  a  distinct  line  of  demarcation  in  many  cases  is  undoubt- 
edly true.    It  is  also  a  notable  fact  that  efforts  to  clarify  the  meaning 


^ Osier:  Modern  Medicine,  2d  ed.,  vol.  i,  p.  550. 
*  Alfred  Smith,  in  Keen's  Surgery,  vol,  i. 


84  INFECTIOUS  DISEASES 

of  these  terms  in  general  use  by  coining  new  words  or  attempting  to 
outline  absolute  limitations  for  their  use  tends  to  make  the  matter  of 
proper  classification  more  instead  of  less  difficult. 

PYREXIA  f FEVER). 

H\'perthermia,  or  ele\ation  of  bodily  temperature  above  normal,  is 
one  of  the  expressions  of  many  pathological  conditions. 

Direct  exposure  to  heat  has  been  known  to  cause  hyperthermia 
in  animals  and  in  small  degree  in  man,  but  the  heat-regulating  adjust- 
ment is  usually  so  effective  that  the  change  from  this  cause  alone  is 
slight  in  indi\'iduals  in  good  health.  Excessive  heat  may  lead  to 
nervous  or  other  disarrangement  of  bodily  conditions,  whereby  toxic 
substances  may  be  produced.  It  is  in  this  way  that  the  heat  centers 
of  the  brain  become  affected  in  sunstroke. 

It  is  important  to  remember,  in  the  treatment  of  fever,  that  causes 
other  than  bacteria  and  their  products  may  incite  increase  of  bodily 
temperature,  and  again  that  fever  is  sometimes  beneficial  in  favoring 
bacterial  conditions  and  then  becomes  one  of  the  natural  efforts  to 
overcome  the  disease. 

Drugs  which  reduce  the  temperature  by  reducing  the  heart's  action 
are  therefore  to  be  avoided,  and  therapeutic  efforts  should  always  be 
directed  to  the  relief  of  the  cause  rather  than  this  sNTnptom. 

Hysteria  and  nervous  diseases  of  such  character  as  to  affect  these 
centers  directly  have  also  been  known  to  cause  fever.  But,  as  a  general 
rule,  fever  is  caused  by  toxic  substances.  These  may  be  from  bacteria, 
or  products  of  the  growth  of  microorganisms,  albuminous  bodies  of 
this  nature,  or  those  developed  quite  outside  of  bacterial  action.^ 

The  irritability  of  the  heat-regulating  center  (presumably  in  the 
basal  ganglia  because  a  proper  heat  regulation  cannot  be  maintained 
unless  certain  parts  of  the  midbrain  are  intactj  is  particularly  sus- 
ceptible to  chemical  action  and  infectious  processes.  Friedberger 
found  that  small  specific  proteid  caused  fever  in  animals  sensitized  by 
that  proteid,  while  collapse  with  subnormal  temperature  and  even 
death  resulted  from  the  injection  of  larger  amounts.  He  holds  that 
anaphylatoxin  is  the  uniform  cause  of  infectious  fevers  by  stimulation 
of  the  heat-regulating  center. 

Aseptic  Fever. — Aseptic  wound  fever,  ferment  fever  (von  Bergmann), 
resorption  fever  (Billroth),  after  fever,  traumatic  fever. 

Etiology. — This  form  of  fever  is  now  believed  to  be  chiefly  if  not 
altogether  due  to  the  absorption  of  nucleins  and  albumoses,  substances 
occurring  in  extra vasated  blood.  This  has  been  proved  by  the  intro- 
duction of  these  substances  into  the  circulation  of  animals.  It  was 
formerly  looked  upon  as  a  result  of  absorption  of  the  fibrin  ferment 
formed  in  extravasated  blood.    That  other  factors  also  enter  into  the 

1  Beilfield:    The  Basis  of  Symptoms,  p.  404. 


PYREXIA  85 

causation  of  fever  following  surgical  operations  under  aseptic  conditions 
is  shown  by  the  well-known  fact  that  rise  in  temperature  may  be  but 
slight  after  severe  operations  and  higher  when  the  operation  is  in  no 
respect  se^•ere.  The  loss  of  large  quantities  of  blood,  the  length  of 
time  of  operation,  imperfect  hemostasis,  bruising  and  strangulation  of 
tissue,  an  undue  amount  of  general  anesthetic,  operation  in  the  region 
of  important  nerves,  and  other  factors  which  govern  the  degree  of 
shock  are  all  important  elements  in  the  increase  of  temperature  after 
surgical  operative  procedures.  Fright  alone  may  so  act  upon  the  heat 
centers  as  to  cause  fever.  Just  where  the  line  of  demarcation  should 
be  drawn  in  a  dogmatic  way,  distinguishing  a  single  element  as  respon- 
sible for  aseptic  wound  fever,  is  uncertain. 

Septic  Fever. — A  fever  caused  by  one  or  more  of  the  forms  of  acute 
general  sepsis,  such  as  toxemia,  septicemia,  pyemia,  and  allied  con- 
ditions. 

Etiology. — ^The  bacteria  generally  gain  entrance  through  wounds 
or  the  mucous  membrane  of  the  alimentary,  respiratory,  or  genito- 
urinary tracts,  or  the  infection  may  occur  in  the  course  of  pneumonia, 
erysipelas,  puerperal  fever,  typhoid  fever,  and  other  similar  diseases. 

Occasionally  it  is  impossible  to  determine  the  point  of  entrance  of 
the  microorganisms,  and  such  an  infection  is  described  as  cryptogenetic. 

Since  the  bacteria  of  septicemia  are  identical  with  those  of  pyemia, 
it  is  difficult  to  understand  why  they  form  foci  of  inflammation  in 
some  cases  and  not  in  others. 

The  organisms  most  frequently  responsible  for  septicemia  in  surgical 
cases  are  streptococci,  staphylococcus,  the  pneumococcus,  Bacillus 
coli  communis,  gonococcus.  Bacillus  pyocyaneus.  Bacillus  aerogenes 
capsulatus,  and  Bacillus  anthracis. 

Symptoms. — There  are  certain  general  symptoms  which  are  typical 
of  cases  of  acute  general  sepsis.  Variation  from  these  and  the  degree 
of  severity  largely  determine  clinical  diagnosis  of  the  type. 

In  toxemia  there  is  usually  a  chill,  although  in  some  cases  this  symp- 
tom is  not  distinctly  marked.  The  succeeding  fever  may  be  only  a 
slight  rise  in  temperature,  varying  from  100°  to  101°  or  102°  F.,  with 
a  tendency  to  become  higher  in  individuals  of  poor  resistance  or  under 
other  unfavorable  conditions.  The  rapidity  of  the  heart's  action  is 
increased,  there  is  usually  a  feeling  of  general  malaise,  headache,  dis- 
turbance of  the  digestive  tract,  and  nervous  symptoms  which  vary  from 
slight  restlessness  to  serious  manifestations  or  delirium.  The  septicemic 
type  may  be  ushered  in  by  symptoms  of  intoxication,  which  may  pro- 
gress slowly  or  rapidly  into  those  of  the  more  serious  form  of  sepsis,  or 
there  may  be  an  initial  chill  of  great  severity  with  rapid  progress  to  a 
fever  of  102°  to  104°  F.,  or  even  higher.  The  pulse  becomes  rapid  and 
irregular,  and  there  is  great  prostration  with  marked  loss  of  flesh,  due 
in  part  to  the  rapid  wasting  under  high  fever  and  in  a  measure  to 
nausea,  vomiting,  diarrhea,  albuminuria,  and  uremic  symptoms  that 
are  quite  commonly  present.    There  is  usually  delirium,  which,  when 


86  INFECTIOUS  DISEASES 

conditions  are  beyond  control,  is  rapidly  succeeded  by  coma  and  death. 
Pyemia  is  sometimes  preceded  by  symptoms  of  intoxication  and 
septicemia,  which  in  due  time  may  be  followed  by  the  metastatic  ab- 
scesses which  mark  the  pyemic  type.  Under  these  circumstances  there 
is  a  tendency  toward  chronic  'pyemia,  which  is  evidenced  by  the  breaking 
out  of  abscesses  in  various  parts  of  the  body.  These  abscesses  some- 
times disappear  and  reappear  during  a  long  period  of  time  without 
marked  acute  symptoms,  such  as  are  generally  incident  to  abscess 
formation,  or  acute  pyemia  may  result  more  rapidly,  with  a  series  of 
chills,  indicating  new  foci  of  inflammation.  These  symptoms  are 
quickly  followed  by  high  fever,  approximately  103°  to  105°  F.;  profuse 
sweats;  sallow  skin;  disorders  of  the  intestinal  tract,  which  may  be 
indicated  by  inability  of  the  stomach  to  retain  food,  diarrhea,  or  con- 
stipation; and  other  s,>nnptoms  that  from  time  to  time  mark  the  efl^'ect 
of  abscesses  of  internal  organs,  especially  the  lungs,  liver,  kidneys, 
brain,  and  joints.  Ulcerative  endocarditis  is  also  likely  to  occur  with 
petechial  hemorrhages. 

Treatment. — In  all  forms  of  general  sepsis  the  first  essential  is  to 
find  and  correct  the  source  of  the  infection.  If  the  focus  be  an  abscess, 
and  is  so  situated  as  to  make  opening  and  evacuation  of  pus  possible, 
that  should  be  done,  proper  drainage  established,  and  suitable  anti- 
septics .  applied.  The  amputation  of  a  gangrenous  extremity,  the 
removal  of  diseased  bone  or  of  an  organ  that  cannot  safely  be  retained, 
is  required  when  such  condition  exists.  In  a  general  way  the  treatment 
of  all  such  cases  requires  therapeutic  measures  designed  to  assist  the 
elimination  of  the  poison  and  reestablish  normal  physiological  pro- 
cesses. To  this  end  saline  purgatives,  calomel,  and  the  drinking  of  large 
quantities  of  water  are  indicated.  Copious  rectal  irrigations  are  some- 
times very  beneficial,  especially  high  bowel  flushing  with  normal  salt 
solution. 

Hypodermoclysis. — In  extreme  cases  the  saline  must  be  given  by 
hypodermoclysis  or  even  by  intravenous  infusions  in  order  to  obtain 
a  more  direct  effect.  The  author  believes,  as  the  technic  becomes 
simplified  and  conditions  governing  hemolysis  better  understood, 
that  the  direct  or  the  indirect  transfusion  of  blood  will  be  more  and  more 
resorted  to  for  overcoming  the  toxic  effect  of  septicemia  and  kindred 
affections  of  the  blood. 

Plondke^  recommends  the  old  method  of  venesection,  combined 
with  the  newer  one  of  intravenous  infusion  of  normal  salt  solution 
for  the  purpose  of  rapid  elimination  of  the  toxins  and  the  neutrali- 
zation by  dilution  or  otherwise  of  those  which  remain.  He  reports 
a  number  of  cases,  in  all  of  which  there  was  an  immediate  abatement 
of  danger  symptoms,  followed  by  prompt  recovery.  He  gave  no  other 
treatment  except  a  dose  of  salts  every  morning  and  a  hot  vapor  bath 
daily  for  a  week,  as  a  matter  of  precaution.  Figs.  50  to  53  illustrate 
the  technic  of  his  method,  which  is  described  as  follows:  * 

1  Jour.  Am.  Med.  Assn.,  January  14,  1911,  pp.  115  and  116. 


PYREXIA 


87 


"Any  prominent  snj)erficial  vein,  preferably  the  median  basilic 
on  the  anterior  surface  of  the  elbow,  is  selected.  Constriction  is  made 
abo\'e  by  applying  a  bandage  just  tight  enough  to  cause  congestion 
sufficient  to  make  the  vein  i)rominent.  The  parts  are  carefully  cleansed 
and  under  local  or  general  anesthesia  an  incision  from  1  to  1§  inches 
in  length  is  made  over  the  long  axis  of  the  vein,  which  is  exposed  by 
carefully  dissecting  it  loose  from  the  contiguous  tissue.  A  double 
ligature  of  No.  1  or  single  0  catgut  is  then  carried  under  the  vein  by 
an  aneurj^sm  needle,  tissue  forceps,  or  other  suitable  instrument  (Fig. 
50,  a),  and  the  two  ligatures  tied  around  the  vein  with  a  single  knot 
at  either  end  of  the  incision,  from  ^  to  f  inch  apart  (Fig.  51,  a,  a).    The 


Fig.  50. — Plondke's  method  of  combined  venesection  and  intravenous  transfusion  of 
normal  saline.     Passing  the  ligature. 


external  surface  of  the  vein  is  then  grasped  with  a  small  rat-toothed 
tissue  forceps  mid\\ay  between  the  two  ligatures  (Fig.  51,  b)  and  divided 
at  this  point  (Fig.  51,  c)  transversely  upward  (or  downward,  as  desired) 
about  half-May  through  its  circumference.  The  end  of  a  thin-walled 
glass  cannula,  with  the  largest  diameter  that  will  be  admitted,  is  then 
inserted  downward  into  the  distal  end  of  the  opening  in  the  vein 
(Fig.  52,  a);  traction  is  then  made  on  one  end  of  the  ligature  (Fig. 
52,  6)  when  the  single  knot  readily  loosens,  allowing  the  cannula  to 
pass  through  the  loop  (Fig.  53,  a) ;  the  ligature  is  again  tied,  this  time 
around  the  vein  containing  the  end  of  the  cannula  (Fig.  53,  b)  (it  is 
important  that  the  lumen  of  the  cannula  is  not  too  small,  otherwise 
the  blood  will  coagulate  and  refuse  to  flow) ;  the  constriction  is  then 


88  INFECTIOUS  DISEASES 

remo\ed  and  another  cannula,  which  may  be  of  smaller  diameter, 
attached  to  a  rubber  tube  coming  from  a  receptacle  containing  a  normal 
salt  solution,  is  inserted  (\\'ith  the  solution  slowl}'  escaping  from  the 


Fig.  51. — Plondke's  method  of  combined  venesection  and  intravenous  transfusion_of 
normal  saline.     Ligature  tied.     Cutting  vessel. 

tube)  upward  into  the  other  (proximal)  end  of  the  opening  in  the  vein 
(Fig.  53,  c)  in  exactly  the  same  manner  in  which  the  first  tube  was 


Fig.  52. — Insertion  of  glass  cannula  into  the  distal  end  of  the  vein. 

introduced.     When  the  desired  amount  of  blood  has  escaped  and  a 
sufficient  quantity  of  salt  solution  introduced  the  tubes  are  carefully 


PYREXIA 


89 


withdraAvn,  while  the  assistant  securely  tightens  the  knot,  obliterating 
the  vein.    The  skin  Axound  may  be  closed  by  any  suture  desired." 

Collargol  (('rede's  preparation  of  colloidal  silver),  2  to  10  c.c.  of  a 
2  per  cent,  solution  of  500  to  1000  c.c.  of  a  0.1  per  cent,  solution  given 
b}'  intravenous  injection,  is  strongly  recommended  by  some  surgeons 
for  its  non-irritating  and  strongly  bactericidal  i)roperties. 

Vaccine  Therapy. — Much  study,  experimentation,  and  clinical 
employment  of  bacteriolytic  sera  have  taken  place  during  recent 
years,  with,  as  might  be  expected,  much  diversity  of  opinion  as  to  the 
result.  That  treatment  of  this  nature  will  bear  an  important  part  in 
the  control  of  infectious  diseases  there  is  no  good  reason  to  doubt.  At 
its  present  stage  of  development,  however,  the  author  feels  that  it 
would  be  unsafe  to  do  more  than  present  the  following  excerpts  from 
recent  literature  as  evidence  of  known  facts  and  experiences. 


.     (^J^jili•'iA'u. 

c- 

I 

*s 

b-- 

A 

s 

1 

a 

^ 

;     C:  0   '-' 

Fig.  53. — Plondke's  method  of  combined  venesection  and  intravenous  infusion. 
Glass  cannulas  inserted ;  one  cannula  attached  to  a  rubber  tube  from  the  receptacle 
containing  saline  solution ;  the  other  allows  control  of  the  escaping  blood. 

All  serious  cases  of  septicemia  are  treated  by  Hagermann  by  injections 
of  antistreptococcus  serum  (10  to  20  c.c.  in  several  doses).  By  repeated 
examinations  of  the  blood  and  pus,  he  is  convinced  that  the  serum  acts 
on  all  streptococci,  but  has  no  specific  action  on  any  one  variety. 
Fromme  stated  that  the  most  virulent  streptococci  give  rise  to  most 
hemolysis;  the  determination  of  this  takes  thirty-five  hours. 

Loberson  has  obtained  50  cures  in  septicemia  out  of  80  cases  by  the 
use  of  antistreptococcus  serum. 

Thomas  arrives  at  the  following  conclusions  as  a  result  of  three  3'ears' 
experience  in  bacterial  immunization.^ 

"In  all,  50  distinct  diseases  T\ere  treated.  Both  by  desire  and 
virtue  of  circumstances,  the  time-honored  measures  of  proved  worth 
were  never  abolished  from  treatment  during  the  periods  of  bacterial 


»  Jour.  Am.  Med.  Assn.,  January  29,  1910. 


90  INFECTIOUS  DISEASES 

inoculations,  because  he  has  always  considered  bacterin  therapy  as  an 
accessory,  not  as  a  specific  agent.  It  was  never  intended  to  be,  nor 
will  it  ever  be,  a  'cure-all,'  but  should  be  regarded  as  an  aid  to  assist 
nature,  in  properly  selected  cases,  to  combat  infection  by  fortifying 
the  organism  through  the  production  of  immunization  by  antibodies. 
In  many  instances  it  has  been  a  difficult  matter  to  decide  how  much 
of  the  cure  should  be  attributed  to  the  usual  method  of  treatment  and 
how  much  to  bacterial  immunization.  Nevertheless,  in  certain  classes 
of  cases  the  results  have  been  consistently  so  striking  that  the  value  of 
inoculation  by  dead  bacteria  is  undeniable. 

"Autogenous  bacterins  are  always  to  be  preferred  over  the  stock 
preparations,  and  success  or  failure  frequentl}^  depends  on  this  fact. 
Although  the  duration  of  the  period  of  greatest  potency  of  bacterins 
is  undetermined,  the  best  results  have  been  obtained  when  the  pus  has 
been  recultured  and  a  fresh  bacterin  prepared  every  two  to  four  weeks. 

"It  is  believed  that  the  best  effects,  therapeutically,  particularly 
in  chronic  cases,  occur  when  the  quantity  is  slowly  and  cautiously 
increased,  thereby,  as  has  been  thoroughly  demonstrated  in  tuberculin 
therapy,  avoiding  hypersusceptibility  or  anaphylaxis." 

TETANUS  (LOCKJAW). 

Tetanus  is  an  infectious  disease  due  to  the  tetanus  bacillus.  It  is 
characterized  by  tonic  spasms  of  the  muscles  which  are  first  manifested 
in  the  jaws  and  neck  and  progress  until  the  muscles  of  the  back  and 
extremities  are  also  involved. 

Etiology. — The  tetanus  bacillus  was  first  isolated  by  Kitasato  in 
1889,  but  as  early  as  1884  Carle  and  Rattone  had  proved  the  infectious 
character  of  the  disease  by  inoculation  of  animals  with  material  from 
the  wounds  of  afflicted  individuals. 

Earth,  especially  garden  soil,  the  dust  of  old  barns,  outhouses,  and 
manure  heaps,  is  the  natural  habitat  of  the  organism. 

It  is  anaerobic,  and  may  develop  spores  after  twenty-four  hours. 
In  a  dry  state  the  spores  may  retain  their  virulence  for  long  periods 
of  time.  They  can  withstand  boiling  for  five  minutes,  and  offer  con- 
siderable resistance  to  antiseptics. 

Cases  of  idiopathic  tetanus  have  been  reported,  and  a  form  of  the 
disease  aftecting  newborn  infants  (trismus  nascentium)  occurs  some- 
what frequently,  but,  nevertheless,  it  is  believed  that  tetanus  can  only 
be  induced  by  entrance  of  the  organism  through  some  lorm  of  inocula- 
tion. Injuries  causing  wounds  of  the  skin  or  mucous  membrane  sur- 
faces are  usually  responsible  for  the  infection. 

The  frequency  of  tetanus  after  accidental  injury  from  firearms, 
fireworks,  and  powder  explosions  has  led  the  Journal  of  the  A7nencan 
Medical  Association  to  prepare  an  annual  list  showing  the  extent  of 
such  Fourth-of-July  injuries,  with  a  view  to  their  prevention.  This 
record,  as  shown  by  the  following  table,  gives  a  trustworthy  indication 
of  this  etiological  feature: 


TETANUS  91 


CAUSES   OF  TETANTIS  CASES. 


Blank 

Giant 

Powder 

Year. 

cartridge. 

cracker. 

Cannon. 

Firearm. 

etc. 

Total 

1903   .      . 

.     363 

17 

5 

3 

27 

415 

1904   .      . 

74 

18 

5 

1 

7 

105 

1905   .      . 

65 

17 

4 

5 

13 

104 

1906   .      . 

.       54 

17 

1 

7 

10 

89 

1907   .       . 

52 

8 

G 

4 

3 

73 

1908  .      . 

58 

5 

4 

3 

6 

76 

1909   .      . 

.      130 

9 

1 

4 

6 

150 

1910  .      . 

64 

2 

5 

1 

72 

Of  the  72  cases  in  1910,  67  (93.1  per  cent.)  ended  fatally  as  com- 
pared with  84  per  cent,  in  1909,  72  per  cent,  in  1908,  85  per  cent,  in 
1907,  and  84  per  cent,  in  1906."i 

Symptoms. — The  incubation  period  varies,  but  usually  occupies 
ten  to  fifteen  days.  The  forms  in  which  the  disease  appears  are  acute, 
chronic  and  cephalic. 

Acute  tetamis  is  indicated  by-  sudden  onset  of  the  symptoms  of 
malaise,  headache,  chills,  stiffness  of  the  neck,  and  tightness  of  the 
jaws.  Lockjaw,  or  tonic  spasm  of  the  masseter  muscles,  follows,  and 
the  contraction  of  the  muscles  of  the  eyebrows  and  of  the  angles  of  the 
mouth  gives  the  appearance  known  as  risus  sardonicus.  As  the  muscles 
of  the  body  begin  to  be  affected  the  back  becomes  curved  and  the  body 
rests  upon  head  and  heels  (opisthotonos) ;  pleurosthotonos,  or  drawing 
of  the  body  to  one  side,  is  less  frequent;  emprosthotonos,  forward 
bending,  occurs  very  rarely. 

The  clinical  picture  is  one  of  great  distress,  and,  once  seen,  never 
to  be  forgotten.  Paroxysms  may  succeed  each  other  rapidly  or  slowly, 
and  the  length  of  their  continuance  be  variable;  dyspnea  and  cyanosis 
are  usually  quite  marked;  the  pain  is  sometimes  intense,  and  the  fact 
that  the  mind  remains  clear  adds  in  untold  measure  to  the  horrible 
agony  of  suffering.  Fever  may  be  slight  or  it  may  reach  a  high  tem- 
perature, 105°  F.  or  more.  Failure  of  the  heart,  or  asphyxia  due  to 
fixation  of  the  respiratory  muscles,  may  cause  death,  or  it  may  occur 
from  exhaustion  within  a  few  hours  or  after  several  days  (approximately 
ten). 

In  one  case  that  came  under  the  writer's  notice,  that  of  a  boy  who 
several  days  before  had  slept  all  night  in  a  barn  and  had  his  fingers  so 
badly  frozen  that  they  required  amputation,  death  occurred  within 
twenty-four  hours  after  the  operation,  and  less  than  that  time  after 
the  first  convulsive  symptoms  were  noticed. 

Chronic  Tetamis. — Chronic  tetanus  exhibits  symptoms  much  the 
same  as  in  acute  cases,  but  with  less  severity.  In  such  cases  the 
disease  sometimes  continues  for  weeks,  with  gradual  tendency  toward 
decrease  in  the  frequency  of  the  spasmodic  attacks,  until  finally 
recovery  ensues. 

1  Jour.  Am.  Med.  Assn.,  September  3,  1910. 


92  INFECTIOUS  DISEASES 

Cej^halic  Tetanus  {Kojjf  Tetaims).- — This  form  occurs  after  injuries 
in  the  region  of  the  distribution  of  the  twelve  cranial  nerves.  It  is 
accompanied  by  paralysis  of  one  or  more  of  the  motor  nerves,  especially 
the  facial,  and  occasionally  by  sensory  disturbance  of  the  trigeminal 
nerve.  The  tendency  is  to  localization  of  the  tetanic  spasms  in  the 
lower  jaw  and  neck  and  in  the  muscles  concerned  in  deglutition  and 
respiration. 

Diagnosis.^ — In  well-developed  cases  diagnosis  is  ordinarily  com- 
paratively simple.  In  tetany  the  symptoms  of  muscular  contraction 
are  chiefly  evident  in  the  extremities,  and  since  it  is  a  neurosis  asso- 
ciated with  hysteria  or  the  toxins  of  t3T)hoid  and  similar  fevers,  there 
is  absence  of  an  abrasion  or  wound  to  account  for  the  infection,  and  a 
clinical  history  which  usually  serves  to  complete  the  diagnosis.  In 
strychnin  poisoning  involvement  of  the  jaw  muscles  appears  late,  if 
at  all,  instead  of  being  an  early  and  constant  s\Tnptom,  as  in  tetanus, 
and  muscular  relaxation  between  paroxysms  is  complete. 

In  the  cephalic  type,  as  the  symptoms  are  chiefly  manifested  by 
spasmodic  contraction  of  the  lower  jaw,  a  number  of  affections  require 
differentiation,  especially  in  cases  of  tooth  impaction  or  after  the 
extraction  of  teeth.  In  one  of  the  author's  cases  of  chronic  tetanus  the 
diagnosis  was  difficult,  owing  to  the  fact  that  the  tetanus  bacillus  had 
gained  an  entrance  through  an  abrasion  of  the  cheek  by  jagged  edges 
of  diseased  roots  of  teeth,  while  the  SAinptoms  readily  might  have 
indicated  infection  from  abscesses  at  the  apical  ends  of  these  roots. 
It  is  well  known  that  direct  irritation  ol  the  inferior  dental  branch  of 
the  fifth  nerve  may  excite  motor  disturbance  and  cause  spasmodic 
contraction  of  the  muscles  of  mastication.  Swelling  in  the  region  of 
the  third  molar  or  around  the  temporomaxillary  articulation  may 
interfere  with  jaw^  movement,  and  in  nervous  patients  excites  symp- 
toms which  might  easily  be  confused  with  the  premonitory  sjTiiptoms 
of  tetanus.  Recognition  of  the  true  cause  and  the  absence  of  more 
general  sjniptoms  makes  the  diagnosis  complete. 

Prognosis.^ — The  mortality  is  variously  estimated  at  from  80  to  90 
per  cent,  before  the  introduction  of  modern  methods  of  treatment, 
and  approximately  40  per  cent,  at  the  present  time.  There  seems  to 
be  a  fatal  tendency  in  cases  in  which  the  period  of  incubation  is  short 
or  less  than  the  usual  ten  days;  in  those,  however,  in  which  the  onset 
is  slow,  and  which  more  nearly  approach  the  chronic  form,  the  prog- 
nosis is  much  more  favorable. 

Treatment.^ — Death  in  tetanus  occurs  primarily  as  a  result  of  the 
direct  action  of  the  toxin  and  because  of  the  exhausting  effects  of  the 
convulsions;  contributing  factors  are  the  starvation,  loss  of  sleep, 
and  the  horror  suffered  by  the  conscious  patient.  Treatment  must 
include  the  following: 

1.  The  bacteria  at  the  seat  of  infection  should  be  destroyed  to  prevent 
further  production  and  absorption  of  the  toxins.  To  this  end  local 
disinfection  and  removal  of  diseased  tissue  must  be  prompt  and  as 


TETANUS  93 

complete  as  possible.  The  agents  chiefly  used  are  bichloride  of 
mercury,  a  2.5  per  cent,  solution  of  carbolic  acid,  creosote,  or  other 
similar  germicides.  Thorough  cleansing  of  the  wound  surface  when- 
ever possible  should  be  supplemented  by  actual  cauterization  and 
swabbing  with  tincture  of  iodin  or  nitrate  of  silver.  Balsam  of  Peru 
is  recommended  by  Hessert^  as  possessing  "some  antagonistic  action 
on  the  tetanus  toxin." 

2.  The  toxins  already  absorbed  from  the  primary  lesions  should  be 
eliminated  from  the  body.  Cathartics,  diuretics,  and  sudorifics  are 
used  as  aids. 

3.  The  circulating  toxin  should  be  neutralized,  since  it  is  at  present 
impossible  to  reach  the  toxin  already  in  combination  with  the  nerve 
cells  and  to  immunize  the  body  after  infection  has  taken  place.  The 
antitetanic  serum  is  used  for  this  purpose.  Reports  as  to  its  value 
differ  as  its  effectiveness  is  influenced  by  many  factors,  but  notwith- 
standing, it  is  generally  accepted  as  the  most  promising  method  of 
treatment. 

4.  Every  effort  should  be  ma'de  to  overcome  the  symptoms  by 
inducing  muscular  relaxation  and  preventing  the  exhaustion  of  the 
tetanic  spasms,  thus  conserving  the  patient's  strength  to  counteract 
the  disease.  The  bromides  and  opium  have  been  used  more  or  less 
successfully  for  this  purpose. 

Spinal  injections  of  magnesium  sulphate  tend  to  eliminate  the 
spasms,  and  seem  to  have  helped  many  patients  to  recovery  who 
might  have  died  under  serum  treatment  alone.  McPhedran^  recom- 
mends the  use  of  a  25  per  cent,  sterilized  solution  of  magnesium  sul- 
phate in  distilled  water,  and  injects  it  into  the  spinal  canal  between 
the  third  and  fourth  lumbar  vertebrae  without  preliminary  removal 
of  spinal  fluid.     He  reports  11  cases,  wath  5  recoveries. 

Recently  the  use  of  chloretone,  introduced  per  rectum  in  30-grain 
doses  with  2  ounces  of  olive  oil,  has  been  highly  recommended.^ 

Chloretone  is  said  to  markedly  decrease  the  rigidity  within  a  definite 
period  after  administration.  Thus  by  relieving  the  trismus  it  enables 
the  patient  to  take  nourishment  and  retain  strength. 

Hutchins  reports  5  cases  in  which  chloretone  was  used  in  connection 
with  antitoxic  seriun  injections.  Recovery  took  place  in  all  except 
1  case,  in  which  death  ensued  from  peritonitis  following  an  intestinal 
perforation. 

Large  doses  of  antitoxin  seem  to  be  required  in  successful  treatment 
of  tetanus.  Charles  H.  Lemon,  of  Milwaukee,  reports  an  interesting 
case  of  a  boy,  aged  twelve  years,  who  stepped  on  a  chicken-bone  in  a 
barnyard  and  was  given  3000-unit  doses  every  three  hours.  In  his 
case  a  total  of  42,000  units  were  given.  The  boy  recovered.  Another 
case  that  he  treated  in  association  with  Caft'rey  has  been  reported  and 

1  Surg.,  Gynec.  and  Obst.,  1909. 

'  Canadian  Jour.  Med.  and  Surg.,  June,  1909. 

»  Surg,,  Gynec.  and  Obst.,  1909. 


94  INFECTIOUS  DISEASES 

published  in  the  Journal  of  the  American  Medical  Association,  No- 
vember 5,  1910,  as  follows: 

"A  case  was  successfully  treated  by  Dr.  A.  J.  Caffrey  with  large 
quantities  of  antitoxin.  The  patient  was  a  youth,  aged  eighteen  years, 
and  symptoms  appeared  about  twelve  days  after  running  a  splinter  in 
the  big  toe  while  barefoot.  In  all,  112,500  units  were  administered. 
The  temperature  never  ran  higher  than  103°  F.  A  rash,  not  unlike 
that  of  scarlatina,  with  intense  pruritus  appeared.  Morphin  was 
resorted  to  with  good  effect,  but  to  CafFrey  it  appeared  the  antitoxin 
effected  the  cure,  and  without  it  he  believes  the  patient  would  have 
died  September  9,  as  on  that  day  the  dyspnea  was  intense  and  the 
patient  became  cyanosed,  but  after  each  dose  he  regained  his  color 
and  got  the  needed  rest." 

Prophylaxis. — Much  attention  is  now  being  given  to  the  prophylactic 
injection  of  serum  in  suspicious  cases.  Murphy^  states  that  "The 
public  should  be  taught  that  all  punctured  wounds  of  soiled  hands, 
feet,  or  face  should  have  a  prophylactic  dose  of  antitetanus  serum. 
Every  patient  with  a  lacerated  or  contused  wound  brought  to  Mercy 
Hospital  receives  an  injection  of  serum  in  the  admission  dressing 
room.  We  have  not  had  a  single  case  of  tetanus  following  this 
treatment." 

In  view  of  the  record  of  the  Journal  of  the  American  Medical  Asso- 
ciation, it  would  seem  that  the  victims  of  injuries  from  fire-works  or 
firearms  must  be  given  promptly  a  prophylactic  dose  of  antitoxic 
sermn  as  a  precautionary  measure. 

For  further  reference  to  this  affection  see  Chapter  XIV. 

TUBERCULOSIS. 

Tuberculosis  is  an  infectious  disease  caused  by  the  Bacillus  tuber- 
culosis. The  characteristic  tubercles  may  or  may  not  be  present. 

Etiology. — The  sputmii  of  consumptives  is  the  chief  medimn  in 
the  transmission  of  tubercle  bacilli.  An  advanced  consumptive 
expectorates  several  billions  of  bacilli  in  a  day.  The  bacilli  dry,  the 
particles  separate,  and  they  are  carried  upon  currents  of  air  and  thus 
form  an  almost  unlimited  infectious  influence. 

Sputum  accidentally  forced  out  in  coughing  or  sneezing,  the  careless 
placing  of  sputum-laden  handkerchiefs  in  pockets,  kissing,  sputum- 
soiled  hands,  infected  articles  of  clothing,  and  similar  means  of  convey- 
ing the  bacilli,  that  can  only  be  prevented  by  the  exercise  of  scrupulous 
care,  are  in  the  vast  majority  of  cases  responsible  for  the  transference 
of  the  infection. 

Flies  are  now  recognized  as  active  agents  in  the  spread  of  tubercle 
bacilli.  Dr.  Ch.  Andre-  has  found  that  after  feeding  on  tuberculous 
sputum  they  evacuate  bacilli  after  six  hours,  and  some  may  be  found 

1  Practical  Medicine  Series,  1911;  General  Surgery,  ii,  140. 
^  Krebs:  Tuberculosis,  p.  49. 


TUBERCULOSIS  95 

in  feces  as  long  as  five  or  six  days  afterward.  Food  thus  polluted 
by  flies  will  affect  guinea-pigs.  Foodstuffs  may  also  be  polluted  with 
bacilli  adhering  to  the  feet  of  flies  after  contact  with  sputum. 

Bovine  tubercle  bacilli  undoubtedly  play  a  more  or  less  important 
part  in  spreading  the  disease.  Koch  denied  this  in  1901,  but  Ravenel 
has  produced  the  disease  in  cattle  with  the  bacillus  from  human 
sources,  and  reports  cases  of  men  infected  accidentally  from  animals, 
and  maintains  that  "human  and  bovine  tuberculosis  are  but  slightly 
different  manifestations  of  one  and  the  same  disease,  and  that  they  are 
intercommunicable. ' ' 

Tubercular  lesions  in  monkeys  and  other  animals  are  in  many 
respects  unlike  those  of  man.  The  tubercle  bacilli  in  fowls,  the  so-called 
avian  tubercle  bacilhis,  for  instance,  is  more  club-shaped  and  branching, 
and  shows  distinct  differences  with  regard  to  culture  media  and  toler- 
ation of  temperature. 

Fish,  notably  carp,  that  are  supposed  to  have  come  in  contact  with 
human  sputum  in  the  water  in  which  they  were  raised  also  show  distinct 
differences  in  temperature  tolerd,tion. 

The  consensus  of  opinion,  however,  is  that  all  of  these  are  different 
forms  of  the  same  disease,  and  due  to  practically  the  same  bacillus. 

Portals  of  Entrance. — ^The  four  distinct  modes  by  which  the  tubercle 
bacilli  gain  entrance  to  the  body  are:  (1)  Inhalation;  (2)  through  the 
digestive  tract  by  means  of  food  containing  the  bacilli,  and  otherwise; 
(3)  direct  inoculation  through  the  skin  or  mucous  membrane  surface; 
and  (4)  intra-uterine  infection  through  the  placental  circulation. 

Pulmonary  entrance  through  the  respiratory  tract  has  long  been 
believed  to  be  by  far  the  most  frequent  mode  of  infection,  but  experi- 
mentation and  clinical  observations  are  causing  a  much  increased 
realization  of  the  importance  of  the  digestive  tract  in  this  regard. 

Owing  to  the  bacteria-laden  sputum,  the  oral  cavity  in  phthisical 
patients  is  constantly  filled  with  tubercle  bacilli,  and  it  has  been 
proved  over  and  over  again  by  Cooke,  Latham,  and  many  bacteriolo- 
gists that  these  bacilli  are  frequently  found  in  the  mouths  of  individuals 
who  have  no  sign  of  tuberculosis.  It  is  also  true  that  carious  teeth, 
diseased  tooth  pulps,  and  gums  frequently  contain  tubercle  bacilli. 
But  in  spite  of  all,  primary  infection  in  this  region  is  comparatively 
rare. 

The  tonsils  appear  to  bear  an  important  part  in  the  causation  of  the 
disease,  and  their  crypts  are  frequently  the  sites  of  primary  infection. 

Intestinal  tuberculosis,  according  to  Osier,  ^  occurs  in  about  30 
per  cent,  of  all  cases.  How  many  of  these  were  primary  it  is  difficult 
to  say.  The  pharynx,  esophagus,  and  stomach  are  rarely  primarily 
involved.  In  children  under  fifteen  years  the  lymph  nodes  are  the  most 
frequent  locations  of  primary  tuberculosis. 

Direct  inoculation  through  abrasions  or  wounds  occurs  frequently. 

^  Krebs:  Tuberculosis,  p.  38, 


9G  INFECTIOUS  DISEASES 

Heredity. — Experimentation  has  proved  that  tuberculosis  can  be 
produced  through  the  semen  and  through  the  placental  circulation, 
and  therefore  hereditary  tuberculosis  can  no  longer  be  absolutely 
denied  as  it  has  been  in  the  past.  These  cases,  however,  deserve  slight 
consideration,  because  of  their  rarity  in  comparison  with  cases  in  which, 
perhaps,  an  hereditary  predisposition  gives  increased  susceptibility 
to  infection  by  the  tubercle  bacillus,  and  in  comparison  with  cases 
affected  through  the  usual  channels. 

Pathology. — Miliary  tubercles  are  small,  grayish-yellow  or  white 
tubercular  nodules,  usually  varying  from  1  mm.  in  diameter  to  the 
size  of  buckshot.  Many  of  them  are  undoubtedly  microscopic.  They 
appear  in  the  course  of  acute  miliary  tuberculosis,  and  may  be  found 
in  great  numbers  throughout  the  principal  internal  organs,  membranes 
of  the  brain,  bone  marrow,  etc.  The  formations  are  not  necessarily 
tubercular,  as  such  nodules  are  sometimes  found  in  other  diseases. 

The  inflammatory  lesions  occur  in  the  tissue  between  and  surround- 
ing tubercles,  although  such  inflammatory  processes  sometimes  develop 
without  recognizable  tubercle  formation.  Caseous  change  takes  place 
in  the  form  of  areas  having  a  dull,  opaque,  lusterless,  grayish-white 
appearance.  Liquefaction  occurs  in  the  necrotic  tissue  thus  formed, 
with  resulting  characteristic  cavities.  In  tuberculosis  of  bone,  cavities 
which  may  be  quite  extensive  are  formed.  These  are  found  to  be  filled 
with  liquefied,  caseous  material,  and  are  known  as  cold  abscesses. 
The  tendency  to  encapsulation  of  tubercular  foci  by  the  formation  of 
fibrous  tissue  is  an  important  feature  of  the  disease  and  one  upon  which 
the  possibility  of  cure  is  largely  dependent. 

Tubercular  lesions  that  have  become  encapsulated  may  remain 
inactive,  or  at  least  without  general  invasion  of  the  tissues,  for  long 
periods  of  time,  and  yet  through  loss  of  integrity  of  the  surrounding 
fibrous  tissue  capsule,  by  infection  or  otherwise,  the  disease  may  become 
general. 

Undoubtedly  through  the  self-limiting  influence  of  tuberculosis 
many  individuals  who  have  been  believed  to  be  free  from  the  infection 
have  at  one  time  or  another  been  affected  by  some  one  of  the  several 
forms  of  tuberculosis. 

It  has  been  claimed  that  all  people  at  some  time  have  been  subject 
to  this  infection. 

Mixed  infection  of  tubercle  bacilli  with  pneumococci,  streptococci, 
staphylococci,  and  other  pathogenic  bacteria  has  been  proved  by 
examination  of  the  blood  and  diseased  areas. 

Special  Forms  of  Tuberculosis. — Organs  Affected. — The  lungs,  pleura, 
lymph  nodes,  peritoneum,  bones,  joints,  and  testicles  are  most  com- 
monly the  seats  of  the  disease.  More  rarely  it  affects  the  ovaries, 
liver,  spleen,  pancreas,  and  muscular  tissues.  Osier  found  275  tuber- 
cular cases  in  1000  autopsies,  and  in  these,  with  few  exceptions,  the 
lungs  were  involved. 

The  order  of  frequency  of  the  disease  in  other  parts,  with  special 


TUBERCULOSIS  97 

reference  to  surgical  tuberculosis,  based  upon  an  estimate  made  from 
clinical  reports,  is  approximately  as  follows:  Bones  and  joints,  78 
per  cent.;  lymph  nodes,  14  per  cent.;  skin  and  connective  tissues,  5 
per  cent.;  genito-urinary  organs,  2  per  cent.;  and  mucous  membrane, 
1  per  cent. 

Tnbercidosis  of  Bone. — As  already  stated,  the  pathological  changes 
which  occur  in  bone  in  the  course  of  this  disease  are  much  the  same 
as  in  other  parts.  Through  circulatory  channels  or  leukocytic  agency 
the  bacilli  become  arrested  in  the  bones,  either  in  the  arterioles  or  in 
the  blind  cul-de-sacs  of  the  venous  terminals,  which  rest  against  the 
epiphyseal  cartilages,  the  sluggish  circulation  of  which  favors  their 
lodgment.  In  this  way  tubercular  foci  are  formed,  and  the  usual  de- 
generative processes  of  tubercular  lesions  occur.  Bone  destruction  and 
absorption,  caseous  degeneration,  and  the  formation  of  sequestra 
may  take  place,  or  the  infarct  so  formed  may  become  enclosed  by  a 
capsule  which  is  exceedingly  hard  and  is  called  an  eburnated  infarct. 
In  the  rare  instances  in  which  the  tubercular  process  occurs  primarily 
in  the  shaft,  it  forms  the  so-ca-lled  tuberculous  osteomyelitis  (osteitis 
sicca  tuberculosa),  which  is  usually  progressive  in  character  and  of 
serious  prognosis.  The  abscesses  are  called  cold  abscess,  as  in  other 
tissues. 

Joint  Tuberculosis. — This  occurs  through  invasion  from  the  neighbor- 
ing bone  or  direct  affection  of  the  synovial  membrane.  It  is  believed 
that  the  cartilages,  ligaments,  and  capsules  are  never  the  primary 
seats  of  the  infection. 

According  to  Konig's  classification,  there  are  three  varieties  of  tuber- 
cular joint  aft'ection :  (1)  Hydrops  (hydrops  serosus,  hydrops  fibrino- 
sus);  (2)  tumor  albus  (fungous,  granulating  joints,  "white  swelling" 
— a  late  form  of  hydrops) ;  and  (3)  tuberculous  suppurati\'e  arthritis. 

Symptoms. — The  symptoms  are  those  of  chronic  inflammation. 
Local  temperature,  pain,  redness,  and  swelling  are  usually  absent  or 
very  slightly  marked.  Naturally  the  conditions  are  modified  when 
there  is  mixed  infection,  and  the  streptococci  or  staphylococci  become 
active  in  the  inflammatory  processes. 

Pottinger  classifies  the  symptoms  and  physical  signs  of  tuberculosis 
in  three  groups: 

1.  Those  due  to  toxemia. 

2.  Those  due  to  reflex  action. 

3.  Those  due  to  tuberculous  processes  per  se. 

When  the  skin  is  involved  in  connection  with  tuberculous  bone 
abscess,  its  color  is  altered  to  a  dull  red,  sometimes  having  a  bluish 
tinge,  and  fistulse  form  in  the  vicinity  of  the  diseased  area. 

Cicatrization  following  the  healing  of  these  fistulous  openings  is 
very  marked. 

The  characteristic  deformities  incident  to  caries  of  the  vertebrae 
are  well  known.     The  cranial  bones,  ribs,  sternum,  jaws,  maxillary, 
and  other  bones  may  be  affected. 
7 


98  INFECTIOUS  DISEASES 

Diagnosis. — In  tuberculosis  of  bones  and  joints  there  is  an  evening 
rise  of  temperature,  which  is  to  some  extent  characteristic  of  all  forms 
of  tuberculosis.  Pain  is  not  a  sufficiently  marked  or  regular  symptom 
to  be  of  much  diagnostic  value.  Tenderness  to  pressure  over  the 
affected  areas  of  bones  or  joints  is  usually  found. 

In  bones  the  presence  of  a  tubercular  lesion  may  sometimes  be 
tested  by  passing  a  needle  through  the  diseased  portion,  and  in  joints 
fibrinous  deposits  and  miliary  granulations  are  to  some  extent  pathog- 
nomonic. These  small  fibrous  bodies  which  have  been  likened  to  rice 
or  sago  grains  are  quite  conunonly  present,  and  the  sensation  to  touch 
that  they  give  when  sliding  between  the  synovial  layers  under  pressure 
with  the  fingers  sometimes  assists  in  making  a  diagnosis. 

The  most  trustworthy  diagnostic  method  in  the  early  stages  is  to 
withdraw  some  of  the  fluid  or  caseous  matter  and  to  demonstrate  the 
presence  of  the  bacillus  therein.  Yet,  as  will  be  shown  from  the  follow- 
ing quotation,  even  this  test  is  not  always  trustworthy. 

"The  examination  of  fluid  taken  from  24  operative  cases  several 
days  before  operation,  all  of  which  were  diseases  of  the  joints,  and  some 
of  which  required  excisions  of  the  major  joints,  showed  6  to  contain 
tubercle  bacilli,  6  pyogenic  organisms,  and  12  were  sterile.  Among  the 
organisms  found  were  streptococci,  staphylococci.  Bacillus  pyocyaneus, 
and  pneumococci.  Of  the  sterile  abscesses,  inoculation  showed  two 
negative  and  one  positive  for  tuberculosis."^ 

Any  stiffening  of  a  joint,  whether  from  slight  muscular  spasm,  or 
inflammatory  adhesions,  when  not  otherwise  satisfactorily  accounted 
for  by  diagnostic  indications,  should  be  viewed  with  suspicion  until 
it  may  be  demonstrated  that  the  cause  is  not  tubercular.  The  .r-rays 
are  A^aluable  in  ascertaining  the  extent  and  character  of  bone  or  joint 
disease  and  as  a  guide  in  determining  the  advisability  of  operation. 

The  maxillary  bones  are  generally  regarded  as  being  rarely  affected 
by  tuberculosis.  How  true  this  may  be  is  perhaps  a  matter  of  uncer- 
tainty, because  the  tubercular  periostitis  and  ostitis,  with  subsequent 
suppuration  and  sequestration,  so  often  closely  resemble  necrosis  from 
other  infections  to  which  the  maxillae  are  prone  that  it  is  extremely 
doubtful  if  correct  diagnosis  could  be  made  in  many  of  these  cases 
except  by  the  exercise  of  unusual  care.  A  careful  demonstration  of 
tubercle  bacilli  in  every  such  case,  if  this  were  possible,  would,  in  the 
author's  opinion,  alter  the  record  considerably,  but  whether  the  result 
would  indicate  an  increase  or  decrease  of  frequency  is  difficult  to  say. 

Typical  tuberculous  bone  lesions  in  this  region  are  most  commonly 
noted  at  the  orbital  margin  of  the  superior  maxillary  or  at  its  junction 
with  the  malar  bone.  The  nasal  and  palatal  bones  are  sometimes 
included  by  extension  of  the  destructive  process.  After  clinical  obser- 
vation of  large  numbers  of  these  cases  the  author  feels  that  only  actual 
demonstration  of  tubercle  bacilli  in  the  diseased  tissue  can  be  looked 

1  Young,  J.  K.:  Am.  Jour.  Med.  Sc,  August,  1910. 


TUBERCULOSIS  99 

upon  as  conclusive.  Even  then  the  actual  cause  may  be  doubtful 
because  there  is  always  a  likelihood  of  mixed  infection,  and  because  it 
is  also  in  this  situation  that  periostitis,  caries,  and  necrosis  of  bone 
occur  so  often,  more  especially  in  young  children.  As  has  already  been 
stated  in  the  discussion  of  necrosis,  it  frequently  follows  as  a  sequel 
of  the  acute  infectious  diseases  which  are  common  in  childhood.  Dento- 
alveolar  abscesses  are  almost  always  present  during  this  period  of  life 
in  connection  with  carious  deciduous  teeth.  Such  suppurative  foci 
form  an  almost  constant  soince  from  which  infection  may  at  any  time 
be  commimicated  to  surrounding  osseous  structures.  The  weakened 
resistance  of  the  maxillae,  owing  to  their  filling  up  with  crowns  of  teeth 
in  the  course  of  development  and  eruption  at  this  time,  renders  them 
more  than  ordinarily  unresisting  to  the  inflammatory  processes  incident 
to  such  infections. 

Ulcerative  and  other  destructive  forms  of  stomatitis  are  likely  to  be 
causative  factors,  and  hereditary  syphilis  not  infrequently  gives  rise 
to  active  manifestations  at  this  time  of  life. 

This  opinion  is  warranted  by  abundant  clinical  experience  in  cases 
of  simple  infection — as  proved  by  then-  prompt  recovery  under  proper 
treatment — that  have  been  allowed  to  progress  and  cause  extensive 
bone  destruction  through  the  mistaken  idea  that  they  were  syphilitic 
or  tuberculous. 

General  Symptoms  and  Diagnosis.— A  detailed  study  of  the  general 
symptoms  and  diagnosis  of  tuberculosis  would  be  outside  the  province 
of  this  work. 

A  brief  resume  of  the  subject  sufficient  to  protect  against  error 
in  determining  the  existence  of  this  disease  may,  however,  bear  an 
important  relation  to  the  therapeusis  or  surgery  of  pathological  con- 
ditions requiring  treatment  within  our  special  field. 

It  should  be  remembered  that  the  term  scrofula,  for  many  years  so 
popular  w4th  the  medical  profession  and  the  laity,  is  no  longer  used. 

In  addition  to  indications  which  may  be  revealed  by  careful  family 
history  and  the  usual  methods  of  physical  diagnosis,  supplemented  by 
.r-ray  examination,  the  following  symptoms  are  important:  Fever 
which  shows  a  persistent  though  not  marked  afternoon  rise  of  tempera- 
ture; chills  and  cyanosis,  although  not  constant,  may  indicate  acute 
conditions  of  this  nature;  i^ersistent  languor  is  always  suspicious; 
digestive  disturbances,  if  accompanied  by  marked  wasting  and  without 
distinctively  demonstrable  reasons  for  the  loss  of  weight,  are  important 
symptoms;  sweats,  dyspnea,  and  emaciation  are  usually  symptoms  of 
the  more  advanced  stages  of  the  disease;  persistent  hoarseness  may 
indicate  lung  or  laryngeal  involvement;  circulatory  disturbance  is 
commonly  noted  in  tachycardia,  which  is  unaffected  by  change  of 
position,  the  pulse  running  persistently  from  90  to  100;  pain  may  or 
may  not  be  distinctive  in  its  manifestations;  the  characteristic  cough, 
expectoration  and  hemorrhage  are  not  likely  to  be  overlooked.  Careful 
examination  of  the  mouth,  nose,  and  throat  should  be  given  to  exclude 


100  INFECTIOUS  DISEASES 

local  causes  of  hemorrhage.  In  spvtvm  examination  it  should  be  remem- 
bered that  tubercle  bacilli  are  frequently  found  in  the  oral  secretions  of 
healthy  people.  On  the  other  hand,  the  finding  may  be  negative, 
because  it  is  usually  only  in  the  advanced  stages  of  the  disease  that  the 
tubercle  bacilli  are  found  in  the  sputum. 

Tubercular  affections  of  the  glands  related  to  the  mouth  and  neck, 
which  are  so  common  in  children,  are  often  troublesome  in  diagnosis, 
because  infection  from  a  dento-alveolar  abscess  may  lead  to  chronic 
enlargement  of  the  nodes,  which  closely  resembles  the  result  of  tuber- 
cular infection.  It  is  useful  to  remember  that  dento-alveolar  abscess 
and  other  septic  conditions  of  the  inferior  maxilla  are  adherent,  whereas 
an  enlarged  lymph  node,  even  though  it  may  be  situated  close  to  the 
inner  side  of  the  jaw,  is  more  or  less  freely  movable.  This  distinction 
does  not  follow  when  the  lymph  node  is  secondarily  infected  from  a 
tooth  abscess  and  independently  enlarged.  It  is  a  good  rule  in  such 
cases  to  examine  carefully  not  only  the  teeth  for  evidence  of  caries  and 
septic  conditions,  but  the  portions  of  the  jaws  in  which  the  crowns  of 
erupting  teeth  may  lie,  because  these  are  sometimes  causes  of  septic 
infection  when  the  outward  s^nnptoms  of  pus  are  not  noticeable. 
Differentiation  must  also  be  made  from  malignant  and  other  tumors 
affecting  the  jaw  and  neck,  from  cysts,  syphilis,  and  Hodgkin's  disease. 
Distinction  in  such  cases  must  depend  upon  recognition  of  positive 
evidences  of  tuberculosis,  or  the  symptoms  by  which  the  other  diseases 
may  be  recognized  and  enumerated  in  the  description  of  these  subjects. 

Tests  for  Tuberculosis. —  The  Tvbemdin  Test. — After  the  first  period 
of  enthusiasm  with  regard  to  its  curative  virtues  when  brought  forward 
by  Koch  in  1891,  tuberculin  was  generally,  and,  as  is  now  known, 
undeservedly,  condemned,  because  of  its  improper  and  unscientific 
use.  At  the  present  time  its  value  as  a  diagnostic  agent  is  universally 
recognized  and  its  therapeutic  possibilities  appear  to  be  constantly 
advancing. 

Tuberculin  (old)  prepared  according  to  Koch's  original  process 
is  now  almost  universally  used  for  diagnostic  purposes.  Its  injection 
gives  a  local  reaction  believed  to  be  due  to  a  combination  of  the  tuber- 
culin in  the  blood  with  the  antibodies  in  the  focus,  manifested  by 
swelling  and  redness  in  the  tubercular  lesions.  The  general  reaction 
which  is  similar  to  that  of  other  bacterial  toxins,  includes,  fever,  malaise, 
sensations  of  chilliness  and  pain  in  the  head  and  joints,  alterations  in 
the  pulse,  and  possible  nausea  and  vomiting.  The  rise  in  temperature 
may  be  slight  or  quite  marked,  and  indeed,  there  may  be  almost  com- 
plete absence  of  active  manifestations  of  the  other  symptoms.  Small 
doses  are  advisable  for  many  reasons.^ 

Cntaneoiis  Reaction. — Von  Firqiiet's  method  is  to  scrape  away  the 
epithelium,  as  in  vaccination,  in  two  areas  an  inch  or  more  apart. 
One  is  moistened  with  tuberculin,  one  part;  five  parts  carbolic  glycerin, 

1  Minor,  Charles  L.:  Krebs's  Tuberculosis,    p.  343. 


TUBERCULOSIS  101 

and  two  parts  normal  salt  solution.  The  other  is  left  as  a  control.  In 
non-tuberculous  individuals  the  reaction  is  alike  at  both  points.  With 
tuberculous  subjects  a  reddened  area,  becoming  more  or  less  encrusted, 
appears  during  the  first  twenty-four  hours. 

Inunction  Test. — Ligniere  and  Moro  found  that  rubbing  a  strong 
solution  of  tuberculin  on  the  skin  produced  reaction,  without  abrasion. 
For  this  purpose  tuberculin  ointment  is  now  prepared  by  reducing 
tuberculin  (old)  to  an  anhydrous  condition  and  incorporating  it  in  a 
lanoline  base  This  should  be  rubbed  for  four  or  five  minutes  over  an 
area  of  several  inches.  In  from  twenty-four  to  forty-eight  hours  a 
zone  of  redness  appears  with  slight  swelling  and  papular  formation. 

Wright's  Opsonic  Index  Test. — By  comparing  the  serum  of  one 
suspected  of  being  tuberculous  with  mixed  sera  of  several  individuals 
known  to  be  free  from  tuberculosis,  there  is  obtained  an  index  to  the 
diagnosis  and  the  treatment.  It  is  believed  that  the  phagocytic  activ- 
ity of  the  tuberculous  person's  leukocytes  varies  from  the  normal  with 
regard  to  tubercle  bacilli. 

The  Ophthalmic  Reaction. — A  1  per  cent,  solution  of  dried  tuberculin, 
alcohol  precipitate,  in  sterile  w^ater  is  dropped  into  the  conjunctival 
sac.  In  from  twenty-four  to  forty-eight  hours,  wath  a  tuberculous 
patient,  the  reaction  will  be  experienced  in  a  feeling  of  discomfort  in 
the  eye,  which  is  quickly  followed  by  conjunctivitis.  Profuse  lacrima- 
tion  takes  place  and  a  fibrinous  exudate  collects  in  the  region  of  the 
inner  canthus.  The  reaction  reaches  its  height  in  the  course  of  eight 
to  ten  hours  and  lasts  two  or  three  days. 

All  the  tuberculin  tests  must  be  considered  in  connection  with 
other  symptoms,  because  there  is  so  much  variation  in  individual 
cases  that  WTong  conclusions  may  easily  be  reached.  The  author's 
experience  with  the  ophthalmic  test,  based  upon  observation,  and  the 
results  as  reported  to  him  from  a  number  of  institutions  in  which  this 
test  has  been  more  or  less  extensively  applied,  is  as  follows:  ^Yhile 
there  can  be  no  doubt  that  the  reaction  does  take  place  in  tuberculous 
patients,  there  is  danger  of  exciting  serious  ocular  disturbance,  and  it 
is  unnecessary  to  incur  this  risk,  since  it  is  admitted  that  the  cutaneous 
and  other  methods  of  tuberculin  diagnosis  are  equally  if  not  more  trust- 
worthy and  do  not  have  this  element  of  danger.  While  serious  eye 
results  may  be  exceptional,  it  is  generally  admitted  that  any  inflam- 
matory disease  of  the  eye  contra-indicates  the  test,  and  since  only 
oculists  can  safely  determine  the  existence  of  such  conditions  with 
sufficient  accuracy,  it  is  obviously  not  a  method  for  general  application. 

Prophylaxis. — Notwithstanding  its  terrible  ravages  in  spite  of  the 
efforts  to  control  the  devastation  it  causes,  tuberculosis  is  a  preventable 
disease.  Enumeration  of  the  methods  that  are  being  projected  and 
adopted  for  its  control  would  mean  a  complete  resume  of  the  history 
of  modern  sanitary  science. 

It  is  sufficient  to  state  that  all  depend  for  their  usefulness  upon 
a  few  simple  basal  principles. 


102  INFECTIOUS  DISEASES 

Destruction  and  prevention  of  the  propagation  of  the  germs  con- 
stitute the  first  principal  division.  The  increase  of  individual  health, 
in  order  that  the  human  body  may  be  in  the  best  possible  condition  to 
resist  and  throw  off  the  infection,  covers  the  second  group  of  important 
considerations. 

Direct  sunlight  is  the  great  enemy  of  tubercle  bacilli,  destroying 
them  in  from  two  to  ten  minutes.  A  diffused  light,  according  to 
Weinzirl,^  destroys  them  in  from  twenty-four  hours  to  one  week. 
Mtoist  cultures  are  much  more  readily  affected  than  dry  ones.  In 
the  dark  corners  of  rooms  tubercle  bacilli  retain  their  vitality  for  long 
periods  of  time. 

Oral  hygiene,  as  commonly  considered,  in  providing  for  proper 
mouth  disinfection,  the  cleansing  of  the  teeth,  the  prevention  of 
dental  caries  and  other  diseased  conditions  of  the  teeth,  alveolar 
structures  and  gums,  is  now  becoming  more  and  more  recognized, 
as  its  possibilities  are  demonstrated  in  the  course  of  development  of 
the  now  world-wide  movement  in  this  direction. 

The  value  of  these  measures  in  contributing  to  more  widespread 
general  health,  and  particularly  to  the  prevention  of  tubercular 
affections,  is  as  yet  only  half-appreciated.  With  full  recognition  of 
this  it  must  still  be  urged  that  there  is,  however,  a  broader  and  more 
important  aspect  of  the  subject  which  should  be  directly  under  the 
control  of  those  "\^■ho  treat  diseases  of  the  mouth  and  teeth.  As  has 
been  shown  in  the  discussion  of  the  subject  of  maxillary  readjustment, 
this  consists  in  the  prevention  and  correction  of  defective  nasal  develop- 
ment (see  pp.  554  and  563). 

Through  the  early  loss  of  teeth,  or  by  permitting  individuals  to 
reach  maturity  with  irregular  or  contracted  dental  arches  and  the 
high,  narrow  palatal  vaults  that  are  associated  with  these  defects, 
both  the  size  and  form  of  the  nares  are  directly  affected,  as  evidenced 
by  the  sections  of  dogs'  heads  on  page  566. 

It  seems  hardly  necessary  to  urge  that  proper  nasal  respiration 
and  the  free  oxygenation  which  depends  upon  the  proper  exercise  of 
this  function  lie  at  the  very  base  of  the  whole  structme  of  prophylaxis 
with  regard  to  tuberculosis,  even  more  than  other  affections.  No 
better  general  remedy  can  be  instituted  than  the  improvement  which 
invariably  follows  the  widening  of  the  nares  by  mouth  expansion,  as 
described  on  page  556,  and  the  immediate  increase  in  the  supply  of 
nature's  most  dependable  agent  in  combating  this  infectious  disease. 
This  should  be  a  routine  measure  with  children,  and  even  young  adults 
whose  upper  dental  arches  and  palatal  vaults  are  narrow. 

Figs.  54  and  55  are  photographs  of  a  boy  patient  nine  years  old 
who  was  referred  by  Dr.  G.  L.  Bellis,  of  Muirdale  Sanitarium,  Mil- 
waukee, with  all  the  symptoms  of  acute  pulmonary  tuberculosis — 
temperature,  night-sweats,  loss  of  flesh,  hoarseness,  and  all  the  classical 

1  Krebs:  Tuberculosis,  p.  49. 


TUBERCULOSIS 


103 


symptoms  of  this  affection  were  present.  An  appliance  was  inserted 
and  his  upper  dental  arch  spread.  Thirty  days  later  his  mother 
reported  that  he  had  gained  in  weight  and  in  height;  one  inch  in  chest 
measurement  and  one  inch  around  the  waist.  He  is  now  quite  well 
(Fig.  56).         _ 

In  summary  it  may  be  said  that  among  the  most  important  measures 
to  be  adopted  in  the  prophylactic  treatment  of  tuberculosis,  there 
should  be  included  all  methods  known  to  dentists  and  oral  surgeons 
whereby  the  cleanliness  of  the  mouth  and  its  secretions,  the  life  and  the 
usefulness  of  the  teeth,  and  the  preservation  of  the  perfect  form  of 
palates  and  dental  arches,  together  with  the  developmental  effect  of 
these  upon  other  parts,  may  be  enhanced. 


Fig.  54. — Front  view  of  tubercular  boy. 


Fig.  55. — Back  view  of  tubercular  boy 
in  Figs.  54  and  56. 


Treatment. — The  local  treatment  of  tubercular  abscess  or  necrosis 
in  the  maxillae  does  not  differ  materially  from  other  similar  affections 
due  to  any  other  cause.  The  removal  of  diseased  tissue  or  bone  and 
of  sequestra,  if  present,  with  packing  and  treatment,  as  described 
under  the  general  heading  of  Necrosis  of  the  Jaws  (p.  336)  is  indicated. 
To  supplement  this  all  the  influences  which  are  known  to  be  beneficial 
in  other  forms  of  tuberculosis  should  be  brought  to  bear  in  assisting 
the  overthrow  of  the  local  infection.  Fresh  air,  highly  nourishing  food, 
and  the  best  possible  hygiene  that  the  circumstances  of  the  patient 
will  permit  are  important. 

How  far  the  general  treatment  of  patients  may  in  the  future  be 


104 


INFECTIOUS  DISEASES 


incorporated  as  routine  treatment  in  connection  with  surgical  tuber- 
cular cases,  it  is  difficult  to  say.  But  the  Stevens  Point  Sanitarium, 
which  is  the  first  institution  regularly  to  adopt  the  combination  of 
surgical  hospital  treatment  in  connection  with  institutional  methods  in 
the  treatment  of  individuals  ordinarily  considered  as  strictly  surgical 
cases,  may  by  its  example  and  results  lead  to  the  general  adoption  of 
this  combination. 

Removal  of  tubercular  glands  is  not  as  generally  resorted  to  at 
present   as   formerly,   although   complete   and   extensive   dissections 

were  generally  effective.  Tuber- 
culin  treatment,  curettement, 
drainage,  and  local  applications 
to  the  affected  glands  are  found 
in  most  cases  to  be  sufficient. 

Murphy^  states  that  he  has 
not  made  a  typical  cervical 
adenitis  operation  in  over  six 
years.  All  except  the  suppurat- 
ing nodes  are  cured  with  tuber- 
culin. The  suppurating  nodes 
should  be  drained  and  curetted, 
not  dissected. 

Summary." — As  an  important 
matter  of  general  information, 
especially  for  those  who  treat 
pathological  conditions,  tuber- 
cular or  other,  in  any  part  of  the 
human  body,  it  seems  best  to 
include  the  following  summary  i^ 
The  following  leaflet,  by  Dr. 
George  H.  Krebs,  of  Los  Angeles, 
California,  submitted  in  compe- 
tition for  the  best  educational 
leaflet  for  mothers,  was  awarded 
a  gold  medal  at  the  International 
Congress     on     Tuberculosis 


Fig.  56. — Same  boy  as  in  Figs.  54 
after  recovery. 


iiid  55 


m 


1908: 


Tuberculosis  a  Disease  Responsible  for  Untold  Sorroiv  to  Mothers. — 
Tuberculosis,  or  consumption,  is  a  disease  which  robs  the  mothers  of 
the  A\orld  of  one  out  of  every  ten  children. 

The  causes  of  this  disease  are  known,  likewise  the  means  whereby 
it  may  be  prevented. 

Every  mother  owes  it  to  herself  and  her  family  to  know  about 
tuberculosis,  so  that  the  lives  of  her  children  may  not  be  placed  in 
peril. 

1  Editor  Practical  Medicine  Series,  1911,  ii,  134. 

^  Krebs:  Tuberculosis,  Appendix,  pp.  808,  809  and  810. 


TUBERCULOSIS  105 

Tlie  Frequency  of  Tuberculosis. — In  the  United  States  more  than 
150,000  persons  die  every  year  from  tuberculosis.  The  great  majority 
of  these  persons  are  in  the  prime  of  Hfe.  Many  of  these  persons  are 
married,  and  their  untimely  death  means  dependent  families  to  be 
cared  for  by  the  State. 

The  loss  in  money  to  the  United  States  from  these  preventable 
deaths  every  year  amounts  to  more  than  three  hundred  million  dollars. 
The  suffering  caused  by  the  disease  is  impossible  to  estimate. 

Two  Important  Facts  about  Tuberculosis. — Tuberculosis  is  prevent- 
able.    Tuberculosis  is  curable. 

These  are  most  important  facts  worthy  of  widest  circulation,  espe- 
cially since  contrary  ideas  prevail. 

Universal  prevention  and  cure  of  this  disease  will  result  only  when 
there  is  universal  effort  against  it. 

In  this  work  of  prevention  and  cure  the  mothers  of  the  world  can 
wield  a  tremendous  influence. 

The  world  counts  on  the  aid  of  the  mothers,  for  what  mother  would 
condemn  either  her  own  or  any  other  child  to  an  unnecessary 
death  ? 

What  Are  the  Causes  of  Tuberculosisf — First,  there  is  an  exciting 
cause,  which  is  a  very  small  plant  called  a  germ.  There  can  be  no 
tuberculosis  unless  this  germ  be  present  in  the  body. 

Secondly,  the  person  who  takes  this  disease  has  a  body  that  is 
favorable  to  it.  Any  person  whose  health  and  strength  are  run  down 
is  predisposed  to  tuberculosis,  because  in  such  a  person  there  is  not 
much  resistance. 

The  two  things  necessary  then  for  tuberculosis  are  the  presence  of  a 
certain  germ  in  the  body  of  a  person  whose  health  for  any  reason  has 
been  run  down. 

What  the  Germ  Does  in  the  Lungs. — When  the  germ  gets  into  the 
body  of  a  person  who  is  run  down  in  health,  it  finds  a  soil  suitable  for 
its  growth  and  produces  the  disease  called  tuberculosis. 

The  germs  produce  little  granules  called  tubercles,  which  may  later 
become  little  ulcers  or  abscesses. 

Poisons  are  also  thrown  out  by  the  germs  and  get  into  the  blood,  and 
these  poisons  cause  most  of  the  symptoms  of  the  disease. 

What  Are  the  Symptoms  of  Tuberculosisf — The  symptoms  are  dif- 
ferent, according  to  the  stage. 

It  is  the  symptoms  of  the  early  stages  that  should  be  learned,  for 
it  is  then  that  cure  can  be  brought  about  and  lives  saved.  What  are 
these  symptoms? 

The  disease  usually  comes  on  in  very  slow  and  mild  fashion.  That 
is  what  throws  the  persons  infected  off  their  guard.  There  may  be 
nothing  more  than  a  tired  feeling,  especially  after  work,  a  lessened 
appetite,  some  loss  of  weight,  and  perhaps  an  occasional  cough. 

As  the  disease  grows  worse,  these  symptoms  do  likewise.  The 
loss  of  weight  may  be  very  noticeable;  there  may  be  fever  and  night- 


i06  INFECTIOUS  DISEASES 

sweats.  With  the  more  frequent  cough  much  sputum  may  be  expec- 
torated. 

In  the  far-advanced  stages  some  of  these  symptoms,  Uke  cough, 
loss  of  weight,  and  fever,  may  be  very  pronounced.  Then  we  have 
the  picture  of  the  "consumptive." 

How  May  Tuberculosis  be  Preventedf — Tuberculosis  may  be  pre- 
vented by  doing  two  things:  (1)  Killing  the  germs  that  cause  the 
disease.  (2)  Having  people  become  healthy,  so  that  they  will  not 
be  predisposed  to  the  disease. 

How  Are  the  Germs  to  Be  Destroyedf — The  germs  are  scattered  far 
and  wide  in  the  sputum  which  is  coughed  up  by  consumptives.  One 
consumptive  can  cough  up  in  a  single  day  several  billions  of  these 
germs. 

When  this  sputum  dries  as  dust  the  germs  are  blown  about  in  all 
directions;  they  get  into  the  air  we  breathe  and  on  the  food  and 
things  we  eat  and  handle.  In  this  way  every  person  at  some  time  in 
life  probably  gets  the  germs  into  his  body. 

To  destroy  these  germs,  all  that  is  necessary  is  to  destroy  the  sputum. 

If  sputum  be  coughed  into  paper  cups  or  napkins,  these  can  be 
burned  and  the  germs  destroyed.  For  spittoons,  disinfectant  solutions 
like  lye  should  be  used. 

Coughing  in  people's  faces  or  spitting  on  the  streets,  and  especially 
on  floors,  is  dangerous. 

How  May  the  Predisposition  of  a  Weakened  Body  Be  Overcome? — 
Bodily  weakness,  that  is,  the  predisposition  to  tuberculosis,  may  be 
overcome  by  right  living,  particularly  by  breathing  pure  air,  eating 
nourishing  food,  and  getting  the  proper  proportion  of  rest  and 
exercise. 

A  child  weak  at  birth  should  be  guarded,  and  as  it  grows  older  made 
to  spend  much  time  outdoors. 

Children  weak  from  diseases  like  measles  or  whooping-cough  should 
not  be  neglected.  These  and  kindred  diseases  are  often  responsible 
for  tuberculosis  being  set  up  later  on  in  life. 

Children  should  not  be  made  to  work  at  too  early  an  age,  or  allowed 
to  study  so  hard  as  to  interfere  with  health. 

The  food  should  be  eaten  slowly,  and  should  always  be  nourishing. 
If  cow's  milk  is  used,  it  should  be  obtained,  if  possible,  from  a  dairy 
having  no  tuberculous  cattle. 

The  living  and  sleeping  rooms  of  the  family  should  always  be  well 
ventilated.  The  hmnan  body,  if  it  is  to  be  in  a  healthy  state,  must 
have  pure  air.  Bedrooms  should  not  be  overcrowded,  and  single  beds 
are  advisable. 

The  above  rules  should  be  observed  by  grown-up  persons  as  well. 

These  simple  rules  are  worth  observing,  because  a  healthy  body  is 
usually  able  to  overcome  tuberculosis,  but  a  weakened  body  is  not. 

How  May  Tiibercidosis  Be  Cured? — ^Tuberculosis  may  be  cured  by 
the  same  measures  which  prevent  it,  namely,  by  making  the  body 


SYPHILIS  107 

stronger  so  that  it  will  be  able  to  kill  the  germs  that  have  gotten  into 
the  tissues. 

Pure  air,  good  food,  plenty  of  rest  treatment,  cures  more  people 
of  tuberculosis  than  all  the  medicines  that  are  known. 

Avoid  patent  medicines  for  tuberculosis,  particularly  cough  medicines, 
as  these  usually  contain  alcohol  and  opiates,  which,  though  they  may 
make  the  patient  feel  better,  usually  allow  the  disease  to  grow  worse. 

The  above  methods  should  be  carried  out  under  the  advice  of  a 
private  or  dispensary  physician  who  has  made  a  study  of  the  disease. 
"Develop  healthy  bodies." 

SYPHILIS. 

Syphilis  is  an  infectious  disease  caused  by  the  Spirocheta  (treponema) 
pallida.  It  is  a  constitutional  affection  that  becomes  chronic,  and  is 
of  indefinite  duration.  Its  manifestations  affect  almost  every  part  of 
the  body,  and  in  a  general  way  are  said  to  represent  primary,  secondary, 
and  tertiary  stages,  to  which  some  writers  add  a  parasyphilitic  stage. 

Syphilis  May  Be  Hereditary  or  Acquired. 

Hereditary  Syphilis. — In  the  transmission  of  syphilis  by  heredity 
the  infection  takes  place  in  the  following  different  ways: 

The  fetus  may  be  infected  by  the  semen  of  a  syphilitic  father  at  the 
moment  of  conception,  or  similarly  by  the  ovum  of  a  syphilitic  mother. 
It  may  also  be  infected  through  the  placental  circulation;  or  receive 
infection  in  parturition  from  lesions  of  the  mother's  genitals 

The  conditions  governing  the  hereditary  transmission  of  syphilis 
vary  greatly.  A  syphilitic  father  may  infect  both  wife  and  child, 
or  he  may  infect  either  without  the  other.  A  syphilitic  mother  may 
bear  an  untainted  child,  although  this  is  admitted  to  be  of  rare  occur- . 
rence;  and  the  appearance  of  late  tertiary  sjinptoms  in  such  mothers 
lends  color  to  the  assumption  that  freedom  from  infection  was  only 
apparent.  Colles'  law,  "that  the  apparently  healthy  mother  of  a 
syphilitic  child  cannot  be  infected  by  the  child,"  is  subject  to  occasional 
exception  in  cases  that  have  been  reported  of  mothers  who  have 
developed  chancre  of  the  nipple  and  general  syphilis  after  nursing  their 
infants. 

The  danger  of  infection  from  the  syphilitic  father  becomes  markedly 
less  after  two  years  and  seldom  occurs  after  five  years,  but  even  then 
there  is  no  certainty  of  safety.  When  proper  treatment  is  given  the 
danger  is  practically  nil  after  five  years,  and  it  is  claimed  that  in  many 
cases  infection  is  not  transmitted  after  two  years. 

A  syphilitic  mother  may  give  birth  to  syphilitic  children  long  after 
her  own  symptoms  have  ceased  to  be  evident.  There  appears  to  be  a 
gradual  tendency  toward  lessening  of  the  virulence  of  the  infection 
with  each  succeeding  childbirth;  but  no  rule  can  be  established  in  this 
respect,  because  with  the  syphilitic  mother  there  may  occur  in  almost 


108  INFECTIOUS  DISEASES 

any  order,  death  in  utero,  monstrosities,  abortions,  children  born  with 
syphilitic  lesions,  or  without  noticeable  imperfection  at  birth,  but 
which  may  develop  luetic  symptoms  at  a  later  period. 

Symptoms. — There  are  no  primary  lesions  or  chancres  in  hereditary 
syphilis;  but  in  many  other  respects  its  manifestations  are  much  the 
same  as  in  acquired  syphilis,  except  for  such  differences  as  are  caused 
by  interference  with  both  intra-  and  extra-uterine  development.  These 
influences,  however,  are  usually  responsible  for  clinical  symptoms 
which  vary  considerably  from  the  results  of  the  same  virus  in  acquired 
cases. 

The  destructive  influence  of  syphilis  as  affecting  fetal  and  post- 
natal development  is  characterized  by  deformities  of  the  cranium, 
spine,  extremities,  chest,  and  other  parts. 

Syphilitic  children  are  often  born  prematurely.  The  wrinkled 
appearance  of  their  faces  marks  the  type  of  one  of  the  stages  of  develop- 
ment which  gives  a  senile  appearance,  the  old  man's  countenance. 
The  skin  is  creased  and  loose,  and  a  macular  eruption  often  occurs. 
Extreme  susceptibility  to  snuffles  in  infants  indicates  inflammation 
in  the  nasal  mucous  membrane.  The  eyes  are  apt  to  be  inflamed  and 
sunken.  Lesions  of  the  nervous  system  may  manifest  themselves  in 
many  forms. 

Digestive  disturbances  assist  in  causing  restlessness,  anemic  appear- 
ance, insufficiency  of  growth  and  weight.  All  these  symptoms  are 
characteristic,  but  not  necessarily  indicative  of  syphilis. 

The  skin  is  affected  by  various  forms  of  eruption.  These  are  maculo- 
papular  eruptions,  squamous,  bullous,  or  pustular,  and  show  a  tendency 
to  regional  distribution  or  to  become  confluent. 

These  indications  are  not  always  present,  but  syphilitic  children 
may  be  born  quite  healthy  in  appearance  and  yet  develop  late  symp- 
toms of  the  tertiary  type,  or  may  appear  to  be  perfect  and  yet  have 
visceral  defects  that  will  lead  to  fatal  lesions  shortly  after  birth. 

Although  the  lining  membrane  of  the  nose  is  highly  susceptible, 
the  mucous  membrane  of  the  mouth  is  not  so  conmionly  aft'ected. 
There  may  be  ulcers  upon  its  surfaces  that  are  difficult  to  distinguish 
from  aphthous  stomatitis,  or  a  notable  tendency  to  fissures  and  crust- 
covered  cracks  upon  the  corners  of  the  mouth. 

The  scars  from  these  cracks  when  healed  are  important  indications 
of  hereditary  syphilis. 

The  Teeth. — ^The  teeth  bear  the  stigmata  of  hereditary  syphilis 
chiefly  in  two  recognized  forms;  although  it  is  admitted  that  this 
disease  may  be  accountable  for  many  dental  malformations  and 
abnormalities. 

HutcJiimon's  Teeth. — They  are  named  after  Jonathan  Hutchinson,  Sr., 
who  first  directed  attention  to  them  as  evidence  of  syphilitic  heredity. 
They  are  small,  peg-shaped,  and  marked  upon  the  incisal  surfaces  with 
crescent-shaped  notches  (Fig.  57).  The  central  incisors  are  most 
affected  and  inclined  toward  each  other. 


SYPHILIS  109 

Founiier's  Teeth. — This  is  a  descriptive  term  sometimes  applied  to 
the  more  common  appearance  of  erosion  principally  affectino;  the  first 
molars,  whic^h  has  been  represented  as  one  of  the  stigmata  of  hereditary 
syphilis.  That  the  peculiar  form  of  the  tooth  crowns  and  other  marks 
of  arrested  development  upon  their  enamelled 
surfaces,  which  are  typical  of  Hutchinson's 
teeth,  or  even  the  defects  described  by  Fournier, 
might  be  and  doubtless  are  often  due  to  syphilis, 
is  beyond  dispute.  This  is  owing  to  the  fact 
that  s^-philis  is  usually  most  active  at  that 
stage  in  the  development  of  the  central  incisors 
and  first  molars    when    arrested  development 

might  be   expected    to   aftect^  them   at   these     heSditil-y"  syphUis^    at 
points.     On  the  other  hand,  it  is  well  known     maturity. 
that  there  are  many  causes  of  arrested  develop- 
ment, other  than  syphilis,  which  leave  the  record  of  their  occurrence 
upon  teeth  in  the  form  of  grooves,  pits,  eroded  surfaces,  and  otherwise. 

Patients  ha\ing  such  teeth  are  commonly  met  with  in  the  practice 
of  most  dentists. 

]\Iuch  harm  has  already  been  done  through  mis  judgment  in  making 
an  attempted  diagnosis  of  hereditary  s^'philis,  without  other  corrob- 
orative indications. 

Faulty  metabolism,  due  to  many  causes  which  may  afi^ect  the  mother, 
and  later  the  diseases  of  infancy,  may  be  accountable  for  the  imperfect 
form  of  tooth  cro^^^lS  and  marks  upon  their  surfaces,  which  in  some 
cases  might  easily  simulate  those  dogmatically  stated  to  be  pathogno- 
monic of  syphilis  alone. 

As  one  of  the  diagnostic  indications  to  be  considered  only  when 
other  signs  of  hereditary  s>T)hilis  are  present,  Hutchinson's  teeth  have 
a  place;  but  beyond  this  their  significance  should  not  be  relied  upon. 

Bones. — The  bones  are  chiefly  affected  by  osteochondntis,  which 
leads  to  distortions  and  enlargements  of  bones  at  the  epiphyseal  line 
and  'periostitis,  which  may  cause  enlargement  or  destruction.  Less 
commonly  all  the  other  lesions  of  bone  that  occur  in  acquired  syphilis 
are  also  active. 

Dactylitis,  an  enlargement  of  the  phalanges  of  fingers  or  toes,  occurs 
more  frequently  than  in  acquired  syphilis. 

Joints. — Arthritis  appears,  if  at  all,  as  a  complication  of  osteo- 
chondritis. 

Muscles. — ^The  muscles  sometimes  suffer  fixation  through  extension 
of  inflammatory  processes  originating  in  periostitis. 

Lymph  Nodes.^ — ^These  are  not  usually  affected  except  secondarily 
to  other  lesions. 

Diseases  of  the  ear  are  common  among  these  children,  and  are  caused 
by  pathological  conditions  of  the  nose. 

The  liver,  spleen,  lungs,  and  testicles  usually  bear  evidence  of  their 
involvement. 


110  INFECTIOUS  DISEASES 

Syphilis  of  the  Third  Generation.^ — A  safe  clinical  position  with  regard 
to  the  transmission  of  hereditary  syphilis  to  the  third  generation  is 
to  assume  that  it  can  be  so  transmitted,  and  may  be  responsible  for 
dystrophic  stigmata  similar  to  those  of  hereditary  syphilis  of  the 
second  generation. 

At  the  same  time  due  allowance  must  be  made  for  the  rarity  of  such 
cases,  as  generally  acknowledged,  and  the  almost  prohibitive  difficulties 
that  lie  in  the  way  of  definite  proof  that  the  afl"ected  offspring  of  a  third 
generation  is  absolutely  free  from  suspicion  of  acquired  syphilis;  that 
both  the  parents  were  likewise  proved  never  to  have  acquired  this 
infection;  that  one  or  both  of  the  grandparents  actually  had  syphilis, 
and  finally  that  the  lesion  or  dystrophy  of  the  individual  in  question 
is  undeniably  due  to  syphilis. 

It  is  these  questions  that  have  led  to  differences  of  opinion  between 
such  authorities  as  Hutchinson,  who  does  not,  and  Taylor  and  Fournier, 
who  do  believe  that  syphilis  is  transmissible  to  the  third  generation, 
and  the  many  syphilographers  whose  opinions  upon  this  subject  are 
less  extreme. 

Acquired  Syphilis. — Etiology. — Syphilitic  infection  is  acquired  by 
sexual  intercourse,  or  extragenitally  by  non-sexual  inoculation. 

A  syphilitic  lesion  in  contact  with  the  most  minute  abrasion,  even 
though  it  be  microscopic,  its  presence  unsuspected,  and  the  contact 
momentary,  may  be  sufficient  for  the  infection  to  be  transmitted. 

It  is  claimed  to  be  impossible  to  inoculate  by  subcutaneous  injection. 
The  virus  from  chancres  and  mucous  patches  is  the  most  active  in 
infection.  But  inoculation  may  take  place  from  the  blood  or  semen  of  a 
syphilitic,  from  gumma,  and  from  an}^  of  the  secretions.  Even  when  the 
inoculating  fluid  does  not  appear  to  contain  vSpirochetse  pallidte,  inocula- 
tions have  been  successfully  made  with  spirochetse  in  the  resulting  lesions. 

Ea-trage7iital  Inoculation. — An  attempted  recital  of  many  of  the 
infinite  niunber  of  different  and  often  surprisingly  unusual  means  by 
which  the  syphilitic  virus  has  been  transmitted  without  sexual  inter- 
course, and  the  anatomical  situations  in  which  the  initial  lesions  have 
from  time  to  time  been  found,  would  be  quite  useless.  But  the  following 
table,  prepared  by  Bulkley  and  reported  by  Keyes,^  may  serve  to  give 
an  idea  of  the  relative  frequency  with  which  such  inocidations  have 
occurred  in  different  parts  of  the  body. 

Cases.  Cases. 

Lip 1810  Perigenital  region  ....  77 

Breast  and  nipple    ....  1148  Legs  and  thigh       ....  73 

Buccal  cavity 734  Forearm 59 

Fingers  and  hand     ....  462  Neck 47 

Eyelids  and  conjunctiva  372  Gums 42 

Tonsils 307  Forehead  and  temple               .  37 

Throat  (deep  oral  and  nasal)  .  264  Ears 27 

Tongue 157  By  vaccination       ....  1863 

Chin 146  By  cupping  and  phlebotomy  745 

Cheek 145  By  circumcision     ....  179 

Trunk 100  By  tattooing 82 

Nose 95                                                                 

Anus .  87                         Total        .            .      .  9058 

1  Syphilis,  p.  56. 


SYPHILIS  ■  111 

The  striking  lesson  to  be  gleaned  by  study  of  this  chart  is  that  the 
lip,  buccal  cavity,  fingers,  and  hand,  so  greatly  outnumber  all  other 
gources  of  infection  save  vaccination  (which  under  modern  methods 
is  no  longer  a  matter  of  common  occurrence) ,  and  the  breast  and  nipple. 

Thus  it  will  be  seen  how  constantly  oral  surgeons  and  dentists  are 
in  the  presence  of  the  danger,  either  of  infecting  themselves,  or  of 
transmitting  the  disease  through  their  instruments  or  hands  to  patients. 

Dr.  William  Carr,  of  New  York,  who  has  had  wide  experience  in 
dealing  with  syphilitic  mouth  affections,  was  able  in  one  of  his  cases  to 
trace  the  extragenital  infection  to  a  dentist,  who  being  the  only  one 
practising  in  a  small  town,  had  under  his  care  at  the  same  time  one  of 
Dr.  Carr's  patients  who  was  syphilitic,  and  another  one  who  came  for 
treatment  afterward.  In  the  latter  the  initial  sore  appeared  in  the 
mouth  and  was  undoubtedly  the  result  of  infection  by  the  dentist's 
instruments. 

Many  such  cases  have  been  previously  reported,  but  it  is  not  always 
possible  to  have  such  an  uncomplicated  record  of  proof  as  was  offered 
in  this  instance. 

Infections  of  dentists,  physicians,  and  surgeons  by  patients  are  much 
more  easily  proved,  and  have  been  of  sufficiently  frequent  occurrence 
to  warrant  every  precaution  that  may  serve  to  guard  against  inocula- 
tion in  the  course  of  operations,  or  treatment  of  patients,  whether 
known  to  be  syphilitic  or  otherwise. 

Kissing,  the  introduction  into  the  mouth  of  instruments,  pencils, 
spoons,  pipes,  cigars,  or  cigarettes  that  have  touched  the  lips  or  mouths 
of  luetic  individuals,  and  the  pernicious  use  of  public  drinking  cups, 
and  other  similar  means  of  spreading  the  infection  are  too  well  under- 
stood to  require  elaboration. 

It  is  more  important  to  attempt  to  measure  the  exact  danger  of  such 
opportunities  for  conveying  the  virus  as  may  occur  in  ordinary  social 
intercourse. 

On  every  hand  there  is  evidence  of  the  uncertainty  of  establishing 
fixed  rules. 

The  great  majority  of  syphilitics  cease  to  be  infectious  after  three 
years.  After  four  years  the  chance  of  transmitting  infection  is  esti- 
mated to  be  one  in  a  hundred,  and  after  five  years  the  danger  is  believed 
to  be  so  slight  as  to  be  hardly  worthy  of  consideration,  and  yet  even 
the  possibility  of  infection,  no  matter  how  vague,  must  be  deemed  a 
social  menace  until  more  definite  limitation  in  this  respect  may  be 
established. 

TJie  marital  relation  for  syphilitics  is  governed  by  the  rule  that 
"viarriage  of  a  syphilitic  is  permissible  only  after  five  years,  during  the 
last  two  of  lohich  he  has  been  toithout  symptoms.^' 

Three  years  of  proper  treatment  with  conscientious  cooperation 
upon  the  part  of  the  patient  is  generally  believed  to  assure  safety  in 
marriage,  but  doubt  in  this  respect  is  suggested  by  cases  reported  in 
which  infection  has  occurred  after  longer  periods  of  time. 


112  INFECTIOUS  DISEASES 

Marriage,  while  not  necessarily  forbidden,  should  only  be  contracted 
after  two  years,  absolute  freedom  from  symptoms,  and  then  only 
under  careful  medical  supervision. 

Jminvnif]/,  in  some  degree  at  least,  has  been  claimed  for  certain  races 
and  individuals,  as  indicated  by  the  negro  race,  which  seems  to  suffer 
less  severely  than  the  white,  and  authentic  reports  of  men  who  have 
cohabited  with  women  during  the  actively  dangerous  stage,  and  vice 
versa,  without  acquiring  the  disease,  although  others  who  have  had 
coitus  with  the  same  individuals  were  infected.  But  even  these 
examples  are  subject  to  so  many  modifying  circumstances  that  positive 
conclusions  appear  to  be  unwarranted. 

Efforts  to  create  an  artificial  immunity  by  the  injection  of  blood 
serum  of  syphilitics,  or  the  juices  of  their  lesions,  have  thus  far  been 
unavailing. 

Symptoros.^Following  sexual  intercourse,  a  slight  abrasion  or 
several  herpetic  vesicles  may  or  may  not  be  apparent,  or,  if  the  infec- 
tion be  extragenital,  the  lesion  through  which  the  virus  gains  entrance 
may  be  noticeable  or  such  as  not  to  attract  notice.  Following  this 
there  are  no  unusual  symptoms  until  after  the  chancre  appears  upon 
the  glans  penis  or  foreskin,  or  at  any  other  part  of  the  body  where 
inoculation  has  taken  place. 

Period  of  Pkimary  Incuijation. — The  period  of  primary  incuba- 
tion is  the  time  between  the  inoculation  and  the  appearance  of  the 
chancre  or  initial  sore.  This  varies  from  ten  days  to  six  weeks.  Usually 
in  from  three  to  five  Meeks  a  single  sore,  at  first  resembling  a  pimple, 
is  developed  at  the  point  of  inoculation.  This  increases  in  size,  becomes 
indurated,  and  later  eroded  or  ulcerated  upon  its  surface.  About  ten 
days  later,  in  typical  cases,  the  glands  in  one  or  both  groins  begin  to 
swell.  Neither  of  these  symptoms  may  be  such  as  to  create  much  dis- 
comfort, as  the  chancre  is  not  very  sore,  and  the  glands  may  not  attain 
sufficient  size  to  give  trouble.  In  this  way  these  symptoms  sometimes 
pass  unnoticed. 

In  the  course  of  three  or  four  weeks  the  chancre  heals  and  leaves 
a  hard  lump  under  the  epidermis,  which  is  typical  of  these  cases. 

In  women  the  chancre  is  often  so  insignificant  in  appearance  and 
symptoms  as  to  attract  no  notice  whatever,  and  it  is  only  with  the 
beginning  of  the  next  stage  that  such  patients  become  aware  of  their 
own  condition. 

Secondary  Incubation  Period. — The  secondary  incubation  period 
begins  with  the  chancre  and  ends  with  the  appearance  of  the  secondary 
symptoms,  one  to  three  months  later  in  ordinary  cases,  but  sometimes 
not  until  five  months  afterward. 

Secondary  symytoms  may  not  develop  if  proper  treatment  has  been 
promptly  instituted,  or  may  even  be  overlooked  under  other  conditions. 
The  secondary  manifestations  of  syphilis  are  in  the  nature  of  an  acute 
toxemia  and  local  lesions. 

Secondary  toxemia  is  noted  in  variable  degree  in  the  form  of  secondary 
anemia,  general  anemia,  loss  of  body  v^ eight,  slight  fever,  prostration. 


SYPHILIS  113 

and  other  sjaiiptoms  which  might  easily  be  confused  with  typhoid 
fever,  malaria  and  similar  affections,  until  the  secondary  lesions  become 
noticeable. 

Secondary  Lesions. — In  tyj)ical  cases  the  characteristic  skin  lesion 
appears  in  the  form  of  a  macular  or  maculopapular  eruption. 

The  scalp  is  covered  with  moist  encrusted  papules  or  scabs. 

The  mucous  membrane  of  the  mouth  and  throat  is  more  or  less 
affected  by  erosions. 

The  l^^nph  nodes  of  the  neck  become  enlarged,  and  there  is  the  usual 
sjTnptom  of  sore  throat. 

Headache  of  general  or  neuralgic  character  and  painful  affections 
of  the  muscles  and  bones,  particularly  in  the  regions  of  the  joints, 
are  more  or  less  marked. 

At  a  subsequent  period,  after  the  first  outbreak  of  secondary  symp- 
toms has  entirely  disappeared,  other  lesions  are  likely  to  appear. 
These  are  exceedingly  variable,  both  as  to  time  of  appearance  and 
character,  and  may  affect  almost  any  tissue  or  organ  of  the  body. 
Quite  often  they  do  not  appear  /it  all,  especially  with  patients  under 
treatment.  Xo  accurate  estimate  can  be  made  of  the  length  of  'time 
that  must  elapse  before  the  secondary  symptoms  cease  to  recur. 

All  these  features  are  well  covered  in  the  following  tables  prepared 
by  Keyes: 

DURATION   OF  SECONDARY  SYMPTOMS    IN  280   CASES. 

Cases. 

Less  than  1  year 17 

1  to  2  years 82 

2  to  3      " 79 

3  to  4      " 25 

Less  than  4  years^ 49 

4  years 17 

5  " 6 

6  "  2 

7  "  1 

8  "  1 

9  "  1 

Total 280 

LATE   SECONDARIES   AMONG   2000   CASES. 

Cases.  Cases. 

4  years 51  17  years 1 


5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 


51 

17  years 

44 

18   " 

34 

19   " 

13 

20   " 

11 

21   " 

14 

23   " 

9 

24   " 

8 

25   " 

11 

30   " 

8 

1 

10  to  30 

4 

4  to  9 

2 

2 
1 
4 
1 
2 
1 
4 
1 

60 
167 


Total      ....     227 

1  Duration  not  quite  accurately  known. 


114 


INFECTIOUS  DISEASES 


Tertiary  Symptoms. — At  any  time  after  the  secondary  incubation 
period  the  tertiary  lesions  may  occur.  (Some  authors  claim  that  in 
-rare  cases  the  tertiary  may  even  precede  secondary  symptoms.)  Or 
they  may  not  develop  for  many  years,  as  indicated  by  the  results  of 
both  Fournier's  and  Keyes'  experiences,  which  have  been  tabulated 
by  cases  in  the  following  form: 


First  year 

Second  year    . 

Third  year 

Fourth  year    . 

Fifth  year 

Sixth  year 

Seventh  j-ear 

Eighth  year    . 

Ninth  year 

Tenth  to  fourteenth  years 

Fifteenth  to  nineteenth  years    . 

Twentieth  to  twenty-ninth  years 

After  the  twenty-ninth  year 


INCIDENCE    OF   TERTIARISM. 

Fournier. 

278 


453 
471 
388 
357 
326 
274 
211 
195 
736 
423 
304 
83 


Total 4499 


Keyes. 

112 

149 

142 

79 

61 

64 

39 

25 

20 

80 

26 

23 

4 

824 


These  are  the  actively  destructive  manifestations  of  syphilis.  They 
differ  from  the  secondary  lesions  in  being  less  infectious  (are  commonly 
believed  to  be  non-infectious);  in  having  greater  malignancy,  and  a 
tendency  to  attack  the  deep  in  preference  to  superficial  structures. 
Any  organ  in  the  body  may  be  affected.  Tertiary  syphilis  occurs  in  the 
form  of  a  syphilitic  granuloma  (gumma),  or  as  a  diffuse,  interstitial 
sclerosis;  in  the  mouth  ulcerating  syphilis  of  the  soft  palate,  and  tonsil; 
necrosis  of  the  maxillary  bones,  and  particularly  of  the  hard  palate 
with  the  usual  perforation. 

Gumma  of  the  tongue  and  cheek  is  a  frequent  result  of  tertiary 
syphilitic  processes. 

Syphilitic  Dystrophies  or  Parasyphilides. — These  are  func- 
tional derangements  of  apparently  toxic  origin,  and  while  they  are 
common  among  patients  affected  by  syphilis  of  long  standing,  yet  the 
fact  is  that  similar  affections  appear  as  the  result  of  other  systemic 
diseases.  It  necessarily  follows  that  they  are  not  always  syphilitic, 
and  their  inclusion  in  description  of  late  syphilitic  manifestations 
must  be  accepted  with  this  understanding. 

Arteriosclerosis,  aneurysm,  spinal  paralysis,  and  other  neuroses 
and  trophic  changes  of  various  kinds  affecting  organs  or  divisions  of 
the  body  are  examples  of  parasyphilides. 

Diagnosis. — The  subject  of  the  diagnosis  of  syphilis  in  its  presen- 
tation to  practitioners  of  all  divisions  of  medicine  demands  an  advance 
word  of  caution,  and  for  many  reasons  this  is  especially  necessary  for 
those  who  treat  diseases  of  the  mouth.  Not  only  are  luetic  lesions 
in  all  stages  frequently  evident  in  the  oral  region,  but  outbreaks  of 
manj^  other  affections  as  well,  and  many  times  these  simulate  lues  so 


SYPHILIS  115 

closely  as  to  make  diagnosis  extremely  difficult.  There  is  a  predis- 
position to  diagnostic  error  which  may  influence  either  patient  or 
operator  in  this  regard,  and  frequently  leads  to  grave  results. 

Too  often  physicians  and  dentists  are  prone  to  consider  as  syphilitic 
almost  any  aft'ection  that  may  resemble  a  syphilitic  lesion,  if  its  etiology 
be  obscure,  and  it  resists  ordinary  therapeutic  or  surgical  measures.  On 
the  other  hand,  patients  who  know  themselves  to  have  been  exposed, 
or  who  may  at  a  previous  time  have  had  symptoms  of  syphilis,  are 
often  in  a  panic  of  fear  over  any  slight  manifestation  of  disease  that 
may  be  so  construed,  and  thus  through  an  excited  imagination  mislead 
the  diagnostician  by  exaggerated  descriptions  of  their  conditions. 
Over  and  over  again  in  the  author's  practice  cases  such  as  the  following 
have  occurred: 

A  young  man  about  town  had  been  under  treatment  for  sore  throat 
and  ulcers  upon  the  mucous  membrane  of  his  mouth  that  were  assumed 
to  be  of  syphilitic  origin  and  w^re  so  treated.  It  was  found  to  be  an 
ulcerative  stomatitis  primarily  induced  by  uncleanly,  ill-fitting  dental 
bridge-work,  which  caused  pericemental  inflammation  and  infection 
of  the  surrounding  mucous  membrane,  aided  by  excessive  cigarette 
smoking  and  a  generally  depleted  systemic  condition.  The  symptoms 
promptly  responded  to  local  treatment  as  soon  as  the  irritating  bridge- 
work  was  removed.  During  several  years'  observation  of  the  case  no 
syphilitic  symptoms  appeared  to  cast  doubt  upon  this  diagnosis. 

Another  case  was  that  of  a  vaudeville  actor  who  had  been  affected 
with  syphilis  for  many  years  and  was  at  the  time  suffering  from 
necrosis  of  his  lower  jaw,  which  had  steadily  become  worse  under 
previous  antisyphilitic  treatment.  Careful  review  of  the  case  led  the 
author  to  believe  that  excessive  use  of  mercury  was  responsible  for  the 
trouble,  and  not  syphilis. 

All  administration  of  mercury  was  stopped,  and  the  case  treated 
as  one  of  ordinary  necrosis,  with  prompt  recovery.  In  this  case  what 
proved  to  be  mercurial  necrosis,  aggravated  by  increased  doses  of 
mercury,  cost  the  patient  about  two  and  one-half  inches  of  his  mandible 
which  came  out  in  the  form  of  a  sequestrum  as  completely  as  if  resected. 
Admitting  that  the  findings  of  this  case  rest  wholly  upon  clinical 
evidence,  it  is  at  least  fairly  certain  that  the  case  would  have  become 
much  more  serious  if  mercury  had  not  been  stopped,  and  still  more  so 
if  it  had  been  continued  in  increased  doses.  If  space  permitted,  the 
moral  and  social  sides  of  the  question  of  ill  results  following  wrong 
diagnosis  due  to  syphilophobia  might  be  just  as  strongly  illustrated 
as  its  clinical  aspect. 

On  the  other  hand,  whole  pages  might  be  filled  with  examples  of 
disaster  following  failure  to  diagnosticate  syphilis,  and  of  treatment 
given  for  other  affections  when  this  was  the  real  disease. 

Diagnostic  Indications  and  Methods. — Clinical. — History:  Scars  or 
other  evidence  of  previous  lesion,  present  symptoms,  and  the  effect 
of  treatment. 


116  INFECTIOUS  DISEASES 

Laboratory. — Identification  of  Spirocheta  pallida,  specific  reaction, 
examination  of  blood  and  tissue,  and  inoculation  of  monkeys. 

To  facilitate  dift'erential  diagnosis,  the  immediate  indications  of 
sjTDhilis  can  best  be  studied  in  comparison  with  those  of  other  affections, 
having  objective  symptoms  likely  to  cause  confusion. 

Clinical  Diagnosis. — Chancre. — This  is  also  known  as  hard  chancre, 
Hunterian  chancre,  indurated  chancre,  s^-philitic  chancre,  and  primary 
sore. 

This  lesion  appears  at  the  point  of  inoculation. 

In  a  large  percentage  of  cases  the  surface  becomes  eroded,  the  color 
varying  from  dark  red  to  dark  gray,  and  it  is  covered  by  a  slight 
seropurulent  discharge.  All  chancres  have  an  indurated  base,  which 
may  be  felt  by  pressure  between  thumb  and  finger,  but  in  the  eroded 
form  this  is  much  less  noticeable  than  in  the  t>q3ical  Hunterian  chancre, 
which  has  a  large  base  surmounted  by  a  distinct  ulcer.  A  rarer  form 
than  either  of  the  other  two  is  the  indurated  papule,  which  is  usually 
found  on  thick-skinned  surfaces.  These  papules  are  small,  dark,  red, 
and  flat,  with  a  scaly  siu-face  when  healing.  Other  differences  in  the 
appearance  of  chancres  are  noted  in  accordance  with  the  different  situ- 
ations in  which  they  may  be  found.  Mixed  infection,  inflammatory 
results  in  various  forms,  and  vegetation  may  complicate  and  alter 
both  the  course  and  appearance  or  chancre. 

Chancres  of  the  lip  (Plate  II,  Fig.  1)  are  the  most  common  of  all 
extragenital  chancres.  They  affect  the  lower  lip  most  frequently,  and 
are  extremely  variable  in  size.  Such  a  lesion  may  be  a  tiny  papule, 
or  a  large,  crust-covered  mass  that  gives  the  patient  much  distress. 
Chancre  upon  the  tongue  is  not  uncommon,  and  is  usually  upon  the 
dorsum  or  the  anterior  border  (Plate  III).  ^Nlore  rarely  the  lesion  is 
found  upon  the  tonsil,  and  still  less  frequently  upon  the  gum. 

Generally  there  is  a  single  initial  sore  in  s\'philis,  but  two  or  more 
may  be  found  if  the  inoculation  at  several  points  has  been  simultaneous 
or  has  taken  place  within  a  sufficiently  short  space  of  time  to  permit 
infection  at  different  places.  ^Multiple  true  chancres  have  been  reported 
to  occur  in  about  25  per  cent,  of  all  cases.  Chancre  is  not  auto- 
inoculable  once  the  lesion  has  appeared,  but  it  has*  been  proved  both 
clinically  and  experimentally  that  after  several  hours,  or  even  a  few 
days,  auto-inoculation  is  possible. 

A  very  important  diagnostic  indication  is  the  lymph  node,  so-called 
"satellite  gland,"  or,  as  jNIcKey^  designates  it,  the  "pilot  gland." 
This  is  the  more  or  less  enlarged  gland  that  is  found  in  the  chain  of 
slightly  involved  IjTnph  nodes  that  drain  the  region  in  which  the 
chancre  is  situated.  The  induration  often  remains,  and  can  be  dis- 
tinguished when  traces  of  the  chancre  have  so  far  disappeared  as  to 
cause  them  to  be  overlooked  unless  attention  is  directed  to  the  part 
through  recognition  of  the  affected  gland. 

The  following  table  sums  up  the  differential  diagnosis.^ 

1  Dental  Cosmos,  August,  1911,  p.  921. 
*  Keyes:  Syphilis,  pp.  246  to  248. 


PLATE  II 


Chancre  of  the  Lip. 


Mucous  Patch. 


PLATE  III 


FIG     1 


Chancre  of  the  Tongue. 


Gumma  of  the  Tonque. 


118  INFECTIOUS  DISEASES 

The  final  test  is  the  advent  of  secondary  symptoms. 

Vincent's  angina  is  sometimes  confused  with  chancre  in  diagnosis. 
The  difference  may  be  established  by  recognition  of  the  characteristic 
bacillus  of  Vincent's  angina.  This  affection  is  accompanied  by  much 
greater  tenderness  and  its  sore  is  more  superficial  than  chancre.  It 
does  not  heal  spontaneously  as  does  the  primary  syphilitic  sore,  and 
improves  under  local  treatment,  which  chancre  does  not. 

Irritation  by  mouth  habits,  and  irregular  or  sharp-edged  teeth  and 
roots  may  make  sores  upon  the  tongue  or  buccal  mucous  surfaces  that 
simulate  the  appearance  of  chancre  very  closely  and  these  may  also 
alter  the  appearance  of  true  chancre.  Removal  of  the  cause  and  local 
treatment  usually  give  prompt  relief. 

Tuberculosis  is  demonstrated  by  the  presence  of  tubercle  bacilli, 
the  absence  of  other  signs  of  syphilis,  and  the  irregular  hypersensitive 
character  of  the  ulcer  as  compared  with  the  shape,  induration,  and 
painlessness  of  chancre. 

The  Secondary  Syphilitic  Oral  Lesions. — Sore  throat  is  caused 
by  ulcerative  syphilids  (the  ulceration  papule).  These  ulcers  form 
principally  about  the  tonsils  and  pharynx. 

The  imicous  patch  is  an  erosive  or  papulo-erosive  syphilid  or  mucous 
papule  (Plate  II,  Fig.  2,  and  Plate  VIII,  Fig.  2). 

Squamous  syphilid,  or  syphilitic  leukoplakia,  is  unusual  in  secondary 
syphilis,  and  is  a  more  constant  tertiarv  manifestation.  (See  Leuko- 
plakia, Plate  VII,  Fig.  2,  and  Plate  VIII,  Fig.  1.) 

Mercurial  stomatitis,  when  salivation  is  not  a  marked  symptom,  is 
occasionally  difficult  to  differentiate  from  the  ulceration  of  secondary 
syphilis.  As  has  been  described  in  one  of  the  author's  cases  (p.  115), 
the  confusion  may  lead  to  serious  consequences.  The  author  is 
convinced  that  there  is  no  constant  feature  of  the  appearance  of  this 
form  of  ulceration  which  may  be  depended  upon  for  safe  diagnosis. 
The  best  test  is  to  stop  the  administration  of  mercury  and  observe 
results.  (For  other  forms  of  stomatitis  which  might  be  mistaken  for 
syphilis,  see  pp.  154-156.) 

Tertiary  Oral  Symptoms. — The  onset  of  tertiaries  about  the 
mouth  and  associated  parts  may  occur  at  any  period  between  one  and 
forty  years  after  contraction  of  the  disease. 

Diffuse  tubercular  syphilitic  infiltrations  on  the  lips  are  caused  by 
confluence  of  the  pajiules  in  the  form  of  thick,  dark  red,  scaly,  or 
ulcerated  infiltrations  of  the  skin.  The  administration  of  mercury, 
potassium  iodid,  or  other  antisyphilitic  treatment  is  the  best  distin- 
guishing test. 

Vegetations  or  small  condylomata  also  appear  upon  the  lips,  and 
their  nature  is  tested  in  the  same  manner. 

Thickening  of  the  lips  without  gummatous  degeneration,  and  show- 
ing no  surface  lesion,  sometimes  results  from  a  diffuse  interstitial 
sclerosis. 

The  tongue  during  this  stage  may  be  affected  by  leukoplakia  (Plate 


SYPHILIS  119 

VII,  Fig.  2,  and  Plate  VIII,  Fig.  1);  interstitial  glossitis  (Plate  XIX, 
Fig.  3)  and  gumma  may  also  occur  (Plate  III,  Fig.  2). 

From  a  diagnostic  point  of  view  it  is  claimed  that  the  only  safe 
course  to  pursue  when  leukoj^lakia  is  present  is  to  consider  that  it  is 
syphilitic  until  proved  otherwise. 

The  exact  distinction  cannot  at  this  time  be  clearly  defined  between 
leukojjlakia,  which  is  so  often  e^'idence  of  s^-philis,  and  the  same 
afi'ection  which  is  also  frequently  a  forerunner  of  epithelioma  as  to  be 
considered  a  precancerous  stage  of  that  disease. 

Sclerosis  of  the  tongue  causes  it  to  become  thickened,  lobulated,  and 
shining,  and  more  or  less  abnormally  white.  As  the  process  advances, 
fissures  and  excoriations  occur  which  are  followed  by  shrinking  of  the 
scar  tissue  with  marked  decrease  in  the  size  of  the  tongue. 

Gumma  of  the  tongue  occurs  rarely,  and  when  it  does  it  is  often 
associated  with  sclerosis  (Plate  III,  Fig.  2). 

The  test  of  these  affections,  as  of  the  preceding  s\Tnptoms,  is  anti- 
syphilitic  treatment. 

The  objective  symptoms,  when  compared  with  those  of  ephithe- 
lioma,  admit  consideration  only  in  a  very  general  way,  because  both 
of  these  affections  are  so  variable  in  their  characteristics. 

Epithelioma  is  more  likely  to  occur  after  the  fortieth  year  of  age, 
and  affects  men  most  frequently.  It  may  be  on  the  under  surface 
as  well  as  other  portions  of  the  tongue,  is  single,  and  may  be  preceded 
by  leukoplakia.  In  appearance  it  is  a  shallow  ulcer  with  thick, 
everted  edges  upon  a  very  much  hardened  base.  It  bleeds  readily 
and  has  a  foul  discharge.  The  pain  is  usually  severe.  The  lymph 
nodes  are  apt  to  be  enlarged  at  an  early  stage,  with  tendency  toward 
progression  in  this  respect.  ^Medicinal  treatment  is  practically 
useless. 

Gumma  has  a  history  of  syphilis;  it  is  not  confined  to  either  age  or 
sex;  it  never  appears  on  the  under  surface  of  the  tongue;  it  may  be 
single  or  multiple,  and  accompanied  by  leukoplakia.  In  appearance  it 
is  a  deep,  sloughing  ulcer,  with  its  edges  undermined  and  more  or  less 
sharp.  The  induration  of  its  base  is  not  as  marked  as  with  epithelioma. 
There  is  less  tendency  to  bleed,  and  the  discharge  is  not  quite  so  offen- 
sive. There  is  usually  little  or  no  pain.  L}Tnphatic  enlargement  is 
not  a  marked  feature.     Mixed  treatment  is  beneficial. 

The  microscope  and  other  laboratory  methods  offer  a  final  test 
in  these  affections. 

The  tonsils,  pharynx,  and  soft  palate  are  frequently  involved  by 
destructive  tertiary  lesions  in  all  forms  (Fig.  58). 

Destruction  of  tissue  by  ulcers  and  resulting  cicatricial  contraction 
furnish  common  examples  of  syphilitic  results  that  are  difficult  to 
overcome. 

Syphilitic  treatment  in  these  cases  furnishes  both  a  test  of  and  a 
check  upon  the  destructive  process. 

Perforations  through  the  hard  palate,  resulting  from  gummatous 


120  INFECTIOUS  DISEASES 

destruction,  which  usually  begin  in  the  nose,  are  familiar  to  all  who  treat 
diseases  of  the  mouth. 

Their  diagnosis  is  usually  simple,  but  the  author  has  had  many 
cases  in  which  portions  of  the  hard  palate  have  been  lost,  which  left  a 
communicative  opening  between  mouth  and  nose  in  the  region  of  the 
hard  palate.  No  history  of  syphilis  coidd  be  established,  and  upon 
discovery  and  proper  surgical  treatment  of  infection  from  septic  con- 
ditions there  was  recovery,  with  total  disappearance  of  the  constitu- 
tional symptoms,  which  were  often  more  confusing  than  the  local 
sjinptoms. 

The  involvement  of  the  maxillary  sinus  in  these  cases,  even  when 
there  is  no  opening  through  the  hard  palate,  is  always  a  matter  of 
importance. 


Fig.  58. — Syphilitic  destruction  of  the  soft  palate. 

Differentiation  in  these  cases,  in  the  absence  of  clear  history  of 
syphilis,  and  without  external  lesions  to  act  as  guides,  is  sometimes 
difficult. 

Intranasal  examination  usually  discloses  ulcerative  conditions  in 
the  region  of  the  ostium;  or  the  nasal  discharges  may  give  the  desired 
evidence. 

Carefully  taken  radiographs  will  sometimes  enable  the  diagnosis 
of  gumma  of  the  antrum  to  be  made  when  other  methods  fail. 

The  characteristic  shape  of  the  bridge  of  the  nose,  through  loss  of 
its  supporting  structures,  is  an  unmistakable  sign  of  syphilis,  except 
where  accidental  injury  or  necrosis  from  other  causes  has  brought 
about  a  similar  destruction.  These  conditions  are  usually  so  clearly 
understood  that  there  is  little  difficulty  in  getting  a  correct  history 
upon  which  judgment  may  be  based. 

Brain  lesions  of  syphilis,  insofar  as  the  mouth  and  its  associated 


SYPHILIS  121 

parts  are  concerned,  have  been  quite  fully  covered  in  the  chapter  on 
Diseases  of  the  Nervous  System. 

Destruction  of  the  maxillary  hones  may  occur  as  with  other  osseous 
structures,  through  expansion  of  lesions  affecting  the  soft  tissue  in  the 
early  stages  of  distinctly  tertiary  disease  which  afi'ects  bone  generally. 

Osteoperiostitis,  (/ummatous  osteoperiostitis,  and  osteomyelitis  may 
cause  destruction  of  a  bone  in  the  form  of  syphilitic  necrosis  with 
exfoliation  of  a  sequestrum;  or  by  slower  necrotic  processes,  by  which 
the  bone  surface  may  be  destroyed  or  left  in  a  carious  condition. 

Osteoperiostitis  may  cause  enlargement,  thickening,  and  alterations 
in  the  form  of  bony  growths. 

Tuberculosis,  neoplasms,  and  other  septic  conditions  which  may 
lead  to  osteomyelitis,  or  chronic  irritations  from  which  periosteal 
thickening  or  alterations  in  the  form  and  structure  of  bones  may  occur, 
must  all  be  differential  by  the  recognition  of  the  special  cause  of  irri- 
tation or  infection,  microscopic  or  other  examination  of  tissue,'  and  by 
the  usual  indications  of  syphilis  and  the  effect  of  treatment. 

Laboratory  Diagnosis. — The  identification  of  the  Spirocheta  pallida 
is  most  easily  accomplished  during  the  early  stages  of  syphilis.  McKee 
recommends  Burrie's  method,  according  to  which  a  drop  of  serum 
from  the  initial  lesion,  mixed  with  Indian  ink,  is  employed,  "which 
makes  the  finding  of  the  organism  almost  as  easy  as  when  the  dark  field 
illuminator  is  employed."  He  says  that  there  is  no  difficulty  in  differ- 
entiating the  long  spiral  delicate  pallida  from  the  coarser  spirochete 
that  are  found  in  the  mouth,  except  the  Spirocheta  dentium,  with  \^■hich 
it  may  possibly  be  confused.  They  may  also  be  examined  alive  from 
the  secretion  of  an  infectious  syphilitic  lesion,  in  the  hanging  drop  or 
under  a  cover-glass;  but  staining  facilitates  their  identification. 

The  process  of  preparing  and  staining  tissue  requires  much  time  and 
skill,  and  for  this  reason  smears  are  much  more  satisfactory  in  the 
examination  for  Spirochetae  pallidae. 

Chancres,  moist  papules,  and  mouth  lesions  are  most  satisfactory  for 
spirochetse  examination.  In  the  secondary  syphilitic  lesions  the  spiro- 
chetse  are  much  fewer  in  number  and  more  difficult  to  identify.  In 
the  later  tertiary  lesions  there  are  practically  none. 

The  Wassermann  Test. — The  Wasseraiann  test  seems  to  outshine 
all  others  at  the  present  time  in  its  efficiency.  No  mention  has  been 
made  of  this  in  the  clinical  diagnosis,  although  it  might  properly  have 
been  added  to  each  and  all  methods  of  differential  diagnosis.  The 
reason  for  this  is  that  the  Wassermann  test  is  reliable  only  in  the  hands 
of  one  who  is  skilful  and  experienced  in  its  use,  and  unless  carefully 
made  it  may  be  misleading. 

R,  Weiss^  describes  an  easy  method  for  Wassermann's  serum,  which 
is  as  follows: 

"The  method  is  based  on  Wassermann's  test,  which  consists  in 

»  Pacific  Med.  Jour.,  August,  1910. 


122  INFECTIOUS  DISEASES 

combining  the  serum  (amboceptor)  with  organ  extract  (antigen)  and 
complement-holding  serum  and  by  allowing  the  mixture  to  stand 
for  a  little  while.  To  recognize  whether  the  complement  has  been 
bound  or  not,  blood  corpuscles  are  afterward  added  and  the  necessary 
immune  bodies.  Usually  sheep's  blood  and  the  serum  of  a  rabbit 
treated  with  sheep's  blood  are  used.  If  the  complement  has  been  used 
up  under  the  influence  of  the  combination  of  syphilitic  serum  and  organ 
extract  no  hemolysis  will  take  place.  If,  however,  the  complement  is 
still  free  it  will  attach  itself  to  the  sensitized  blood  corpuscles  and  will 
dissolve  them.  For  the  modified  method  it  is  therefore  necessary  to 
have  the  following  materials  for  the  test: 

"Physiological  salt  solution,  prepared  by  dissolving  one  salt  tablet 
in  12  c.c.  of  water. 

"Antigen  (alcoholic  organ  extract). 

"Complement  (guinea-pig  serum,  dried  upon  filter-paper). 

"Amboceptor  (hemolytic  immune  serum  prepared  against  human 
red  corpuscles). 

"Patient's  serum. 

"Emulsion  of  human  red  cells  (obtained  by  collecting  10  to  12  drops 
of  blood  from  the  patient,  transferring  it  to  the  defibrinator,  and  shaking 
vigorously  until  filaments  of  fibrin  are  seen  attached  to  the  beads). 

"  Open  the  bottle  containing  the  antigen  and  draw  the  fluid  up  into 
the  dark  amber  glass  pipette  to  the  graduation.  Eject  this  into  tube 
No.  1.  Add  2  c.c.  of  salt  solution  to  the  antigen  in  tube  No.  1.  Place 
2  c.c.  of  salt  solution  in  tube  No.  2.  (This  tube  from  the  'Control.') 
Place  two  complements  in  each  test-tube.  These  must  be  completely 
immersed  in  fluid.  Take  up  the  defibrinated  blood  in  the  light  brown 
pipette  to  the  graduation  mark.  Transfer  this  to  tube  No.  1.  Put 
an  equivalent  amount  of  defibrinated  blood  in  tube  No.  2.  Let  the 
two  tubes  remain  in  at  the  temperature  of  the  room  for  an  hour.  Shake 
from  time  to  time. 

"  By  means  of  the  ungraduated  pipette  transfer  the  contents  of  one 
amboceptor  bulb  to  tube  No.  1  and  a  similar  quantity  of  amboceptor 
to  tube  No.  2.  Shake  well.  Ten  to  fifteen  minutes  later  again  shake. 
In  a  short  time  the  control  tube  (No.  2)  will  show  solution  of  the  blood 
corpuscles  and  the  liquid  will  become  red. 

"In  tube  No.  1,  if  the  reaction  is  negative,  the  appearance  will  be 
identical  with  those  in  the  control  tube  (either  at  the  same  time  or  a  little 
later).  If  the  reaction  is  positive,  tube  No.  2  will  show  a  sedimenta- 
tion of  the  red  corpuscles,  but  no  solution,  and  in  about  thirty  minutes 
the  blood  corpuscles  Mill  have  settled  to  the  bottom  of  the  tube  without 
the  blood  cells  being  dissolved,  and  the  supernatant  liquid  will  be  clean 
and  light.  A  certain  amount  of  solution  of  the  red  corpuscles  may  take 
place  in  tube  No.  1  if  it  is  allowed  to  stand  for  some  hours." 

This  appears  to  be  a  modification  in  part  of  the  simplified  Wasser- 
mann  reaction  proposed  and  demonstrated  by  Hideyo  Noguchi  in 
1909. 


SYPHILIS  123 

According  to  recent  writers^  the  Wassermann  test  is  not  absolute, 
because  it  is  said  to  occur  in  a  number  of  other  affections. 

Baum^  states  that  the  reaction  occurs  in  scarlatina,  pellagra,  Hodg- 
kin's  disease,  leprosy,  and  in  a  number  of  other  affections,  and  does  not 
always  occur  in  syphilis. 

Prophylaxis. — Experimentation  has  proved  that  syphilitic  secretions 
cease  to  be  infectious  after  twelve  to  twenty-four  hours,  and  in  approxi- 
mately six  hours  if  dry. 

The  importance  of  this  cannot  be  overestimated  when  considering 
the  frequency  of  exposure  to  extragenital  infection  and  its  prevention. 
The  general  substitution  of  individual  for  public  drinking  cups,  and 
the  installation  of  bubblers  at  fountains,  with  other  similar  efforts  toward 
protection  now  being  instituted  by  health  boards,  are  useful  prophy- 
lactic measures  in  fighting  sj^Dhilis  in  common  with  other  infectious 
diseases.  Prevention  of  exposure  to  sexual  infection  does  not  seem 
to  make  satisfactory  progress  in  spite  of  much  agitation.  Control  of 
the  social  evil  at  present  seems  to  be  beyond  municipal  regulations, 
and  until  this  problem  is  solved,  syphilis  cannot  be  wholly  pre- 
vented. 

Prophylactic  Treatment.— No  radical  treatment  of  the  chancre  alone 
can  prevent  the  development  of  subsequent  symptoms,  and  even  wide 
excision  of  tissue  at  the  point  of  inoculation  has  been  proved  to  be 
futile.     Antiseptics  also  are  useless. 

The  only  satisfactory  means  of  aborting  the  disease  appears  to  be 
by  inunction  with  mercurial  ointment  within  one  hour,  certainly  not 
later  than  six  hours,  after  inoculation.  A  salve  of  calomel  20  and  lano- 
line  40  has  been  proved  to  be  a  preventative  when  applied  experimen- 
tally to  monkeys  and  man. 

Treatment.  —  Early  Treatment.  —  In  the  beginning  of  treatment 
patience  and  firmness  must  be  combined  with  much  diagnostic  skill. 
It  seems  needless  to  call  attention  to  the  importance  of  great  care  in 
endeavoring  to  avoid  error  in  diagnosis,  and  the  difficulties  in  this 
direction  have  already  been  explained.  Once  the  existence  of  the 
disease  is  established  the  whole  scheme  of  treatment  should  be  gone 
over  carefully  with  the  patient. 

Instructions  to  Patients. — 1.  The  idea  must  be  impressed  upon  the 
mind  that  the  condition  is  not  hopeless;  but  in  time,  by  conscientiously 
following  instructions,  much  may  be  done  to  avoid  the  evils  that  might 
otherwise  ensue. 

2.  It  must  be  made  plain  that  successful  treatment  depends  largely 
upon  self-control  and  patience  to  continue  the  necessary  restrictions 
and  therapeutic  measures  steadily  through  a  period  of  at  least  two  or 
three  years;  that  general  hygiene  demands  that  there  be  an  abstinence 
from  the  use  of  alcohol  and  the  excessive  use  of  tobacco ;  that  the  hours 

1  Fox:  New  York  Med.  Jour.,  December  18,  1909.  Am.  Jour.  Med.  Sc,  May,  1910. 
Kahn:  Am.  Med.  Record,  June  18,  1910. 

2  Editor  Practical  Medicine,  Series  9,  1910,  p.  100. 


124  INFECTIOUS  DISEASES 

of  sleep  be  sufficient  and  regular;  and  that  bathing,  exercise,  moderation 
in  work,  and  careful  selection  of  simple,  wholesome,  highly  nourishing 
food  be  made  matters  of  routine  habit. 

3.  Habits  and  rules  of  life  which  may  serve  to  looted  others  from 
becoming  infected  must  be  taught. 

4.  Oral  hygiene  must  be  properly  explained.  Instructions  should  be 
given,  making  it  possible  an  immediate  or  early  detection  of  any  syphil- 
itic lesion  that  may  appear  in  this  region.  Such  instructions  may  also 
be  expected  to  reduce  the  danger  of  transmission  of  the  infection 
through  the  oral  secretions,  and  aid  in  the  preservation  of  the  teeth  and 
the  prevention  of  local  lesions.  They  should  include  directions  as  to 
the  proper  use  of  the  toothbrush,  disinfection  of  the  mouth  secretions 
with  suitable  mouth  washes,  and  the  habit  of  daily  inspection  of  the 
teeth,  gums,  tongue,  and  the  buccal  mucosa  generally. 

During  the  administration  of  mercury  the  first  manifestations  of 
salivation  appear  in  the  mouth  and  around  the  teeth  at  the  gingival 
margins.  It  is  of  the  utmost  importance  that  calculi  and  bacteria- 
laden  concretions,  which,  unless  properly  removed,  have  a  tendency 
to  lodge  between  and  at  the  necks  of  the  teeth,  should  not  be  allowed 
to  excite  gingivitis,  as  this  might  be  mistaken  for  the  beginning  of 
excessive  mercurialization,  and  lead  to  reduction  of  the  dosage  of 
mercury  at  a  time  when  it  properly  should  be  increased.  The  effect 
of  such  an  error  might  be  serious. 

The  proper  care  of  the  teeth  must  also  be  urged  in  the  light  of  a 
more  indirect  but  not  less  important  benefit  in  maintaining  a  healthy 
condition  of  the  stomach  and  intestinal  tract.  This  is  most  necessary 
in  assisting  the  system  to  do  battle  with  the  infection  and  to  hasten 
its  overthrow,  as  well  as  to  overcome  the  ill  effects  that  so  often  follow 
the  administration  of  remedies. 

Finally,  it  may  be  said  that  with  intelligent  oral  hygienic  precautions 
practically  all  of  the  very  serious  destructive  processes  which  have 
already  been  described  as  affecting  both  bone  and  soft  tissues  may  be 
avoided. 

Next  to  general  and  oral  hygienic  treatment  tonics  are  indicated, 
for  keeping  up  the  highest  state  of  bodily  health  and  activity  is  an 
important  factor  in  preventing  the  progress  of  the  disease. 

Administration  of  Mercury. — For  a  long  time  mercury  has  been  the 
one  dependable  agent  in  the  treatment  of  early  syphilis.  It  may  be 
administered  by  mouth,  inunction,  inhalation  or  injection,  with  vary- 
ing estimates  of  its  value. 

Internal  Administration.— -The.  remedies  generally  used  are:  (1) 
The  protoiodide  (hydrarg.  iodid.  flav.),  6  granules  of  a  centigram  each, 
given  daily  for  a  minimum  dose  and  gradually  increased  as  indicated ; 
(2)  gray  powder  (pulv.  hydrarg.  cum  creta.),  6  grains  daily  in  1-  to  2- 
grain  tablets;  and  (3)  bichloride  of  mercury  (hydrarg.  chlorid.  corrosiv.), 
in  3^- -grain  doses  in  pill  or  capsule  to  avoid  its  irritating  effect. 

Many  combinations  of  mercury  with  tonics  are  recommended, 


SYPHILIS  125 

according?  to  the  fancy  of  their  special  advocates.     An  example  of  these 
is  the  well-known  pill  of  mercury  and  iron. 

I^ — Massse  hydrargyri, 
Forri  reducti, 

Gum  tragacanth aa     3j  (4  grams) 

GlyRcrin q.  s.  aa 

M.  et  fiant  pil.  no.  Ix. 

Sig. — -One  pill  after  each  meal. 

Intramuscular  Injections. — To  avoid  the  digestive  disturbances 
which  sometimes  result  from  the  internal  administration  of  mercury 
and  in  the  hope  of  securing  a  more  prompt  effect,  injections  into 
the  substance  of  some  thick  muscle  are  employed.  The  following 
prescription  is  among  the  best  of  the  soluble  preparations  for  this 
purpose : 

I^ — Hydrarg.  chlorid.  corrosiv gr.  xv-xxx  (1-2  grams) 

Sodii  chlorid gr.  x  (0.6  gram) 

Aquse  destillat giij  (100  c.c.) 

Dose. — 1  c.c.  (TTlxv). 

Gray  oil,  according  to  G.  S.  Walton,^  is  extensively  used  with  satis- 
factory results  in  the  Liverpool  Skin  Hospital  for  intramuscular  injec- 
tions, and  has  entirely  superseded  the  oral  administration  of  drugs 
in  these  cases.     The  formula  is : 

I^ — Purified  mercury 40  grams 

Sterilized  anhydrous  wool  fat 12       " 

Sterilized  white  petrolatum 13      " 

Sterilized  liquid  petrolatum 35       " 

Five  minims  of  the  dose  employed  are  equivalent  to  2.5  grains 
of  mercury.  As  a  substitute  for  gray  oil,  an  emulsion  of  metallic 
mercury  is  employed  in  the  form  of  a  thick  mixture  of  50  per  cent, 
strength.  The  following  formula  is  offered  by  Lafay  as  being  equally 
as  good  and  much  more  easily  prepared : 

I^ — Hydrarg.  bidestillat Siiss  (10.0  grams) 

Albolin 3iij     (13.5  grams) 

Lanolin giss    (46.5  grams) 

Sig.— Shake.     Dose:     mij  to  vj  (0.1-0.4  c.c.) .2 

These  injections  are  repeated  at  intervals  of  from  one  to  two  weeks 
for  a  year  or  longer  if  indicated.  Later  they  are  repeated  at  intervals 
of  several  months,  according  to  indications  of  the  case.  The  objections 
to  intramuscular  injections  are  pain,  the  tendency  to  poisoning,  and 
embolism. 

Inunctions. — Inunctions  of  blue  ointment  or  any  of  the  mercurial 
ointments  are  rubbed  upon  different  portions  of  the  body  upon  succes- 
sive days  to  avoid  irritation  and  poisoning.  This  is  continued  daily 
for  a  period  of  several  weeks  or  until  the  patient  begins  to  show  slight 
salivation. 

1  New  York  Med.  Jour..  March  26  ,1910. 
*  Keyes:  Syphilis,  p.  176. 


126  INFECTIOUS  DISEASES 

Fumifiation. — Biweekly  fumigations  with  black  oxide  5ij-iiss  (8  to 
10  gm.)  is  sometimes  employed,  or  calomel  may  be  used  for  the  same 
purpose.  These  vapor  baths  are  useful  if  properly  given,  but  other- 
wise are  not  satisfactory. 

Intravenous  Injections. — Intravenous  injection  is  usually  given 
according  to  Bacelli's  formula  t^ 

I^ — ^Hydrarg.  bicUorid 1  gram 

Sod.  ctJorid 3  grams 

Aquffi  destillat 1000       " 

However  valuable  this  method  of  treatment  may  be,  the  well-known 
objections  and  dangers  incident  to  intravenous  injections  would  pre- 
clude its  recommendation  except  for  cases  in  w^hich  there  is  some 
urgent  objection  to  other  means  of  administration. 

Potassium  Iodide  and  Mercury. — In  the  later  stages  of  s^^hilis 
the  mixed  treatment  of  potassimn  iodide  and  bichloride  of  mercury, 
according  to  the  following  formula  or  some  similar  combination, 
has  long  held  sway: 

I^ — Hydrarg.  chlorid.  corrosiv gr.  j-ij  (0-  1.2  grams) 

Potass,  iodid 5ij-3j    (8-30.0  grams) 

Syr.  sarsaparillse  comp ad  giv  (ad  130  c.c.) — M. 

Sig. — One  teaspoonful  two  hours  after  meals. 

In  the  tertiary  stage  the  author  has  frequently  obtained  good  results 
by  the  use  of  potassium  iodide  given  in  the  saturated  solution  in  drop 
doses.  He  begins  with  5  drops  three  times  a  day,  increasing  1  drop 
each  time  until  the  limit  of  endurance  appears  to  be  approaching  or 
until  15  minims  has  been  reached;  then  he  gradually  goes  back  to  the 
original  number;  again  increasing  to  a  point  slightly  beyond  the  last 
maximum  dose.  This  procedure  is  repeated  throughout  treatment. 
In  this  way  the  danger  of  iodism  is  to  some  extent  avoided  and  the 
individual  tolerance  measured.  It  is  well  known  that  both  mercury 
and  potassium  iodide,  particularly  the  latter,  must  be  administered 
with  due  regard  for  the  extreme  susceptibility  to  poisoning  that  is 
occasionally  encountered  in  certain  patients. 

Mercurialism  and  Iodism. — "When  mercury  is  administered  the  ap- 
pearance of  the  dark,  inflamed,  slightly  everted  gum  borders,  loosen- 
ing of  the  teeth,  increased  flow  of  saliva,  and  disturbance  of  the  intes- 
tinal tract,  as  well  as  the  ulcerative  conditions  which  sometimes  occur 
when  these  premonitory  s^auptoms  are  not  noticed,  must  be  constantly 
watched  for,  and  the  dosage  must  be  regulated  in  accordance  with  these 
indications.  With  potassium  iodide,  indigestion,  the  characteristic 
eruption,  tendency  to  neuralgic  pain,  localized  edema,  and  congestion 
of  the  salivary  glands,  with  sjonptoms  of  salivation  and  albuminuria, 
are  among  the  symptoms  that  must  be  taken  as  a  warning  in  regulating 
the  dosage  of  this  drug. 

iKeyes:  Syphilis,  p.  189. 


CHANCROID  127 

Arsenic. — The  use  of  arsenic  has  been  actively  urged  by  many 
syphilographers  during  recent  years.  Sodium  cacodylate  is  recom- 
mended by  Murphy  in  doses  of  1  to  2  grains  hyj)odermicalIy  into  the 
muscles.  He  claims  a  striking  effect  of  this  treatment  upon  syphilis, 
mucous  patches,  and  primary  chancre,  and  that  the  treponemata 
disappear  completely  in  forty-eight  hours.  Ulcers  of  the  palate  and 
posterior  wall  of  the  pharynx  heal  as  healthy  granulating  wounds  in 
from  three  to  six  days. 

Saharsan. — The  most  recent  as  well  as  the  most  promising  prepara- 
tion is  the  widely  heralded  Ehrlich's  salvarsan  ("606")  or  dioxy- 
diamidoarsenobenzol.  This  remedy  undoubtedly  does  give  a  decidedly 
alterative  effect  from  a  single  intramuscular  or  intravenous  injection. 
Its  influence  upon  latent  luetic  lesions  appears  to  be  unquestioned. 
That  it  could  not  cure  all  cases  and  all  conditions  of  syphilis  in  one 
treatment  is  to  be  expected;  that  its  proper  employment  in  the  future 
will  give  good  results  as  its  possibilities  and  limitations  become  better 
understood  is  also  unquestioned.  How  far  the  criticisms  that  seem  to 
be  supported  by  reports  of  untoward  effects  may  prove  to  be  well 
founded,  and  how  many  of  the  ill  results  that  appear  to  have  been 
occasioned  by  its  use  may  be  due  to  faulty  technic  is  a  matter  that  the 
future  will  undoubtedly  settle.  IVIany  cases  have  been  reported  as 
receiving  marked  and  immediate  relief  from  sj-mptoms  when  doses  of 
0.3  to  0.6  gram  have  been  given  by  the  intramuscular  or  intravenous 
routes,  or  a  combination  of  the  two. 

Fordyce  recommends  the  intravenous  injection  of  "606,"  to  be 
followed  by  mercurial  injections  for  a  period  of  from  four  to  six  weeks. 
At  the  expiration  of  this  interval  a  second  intravenous  injection  of 
salvarsan  is  given  and  followed  by  another  similar  period  of  mercurial 
treatment.  After  a  rest  of  one  month  a  Wassermann  test  is  given,  and 
if  negative  the  serum  reactions  are  made  at  intervals  of  several  months; 
and  as  long  as  they  remain  negative  no  treatment  is  given.  If  at 
any  time  the  Wassermann  reaction  becomes  positive,  the  intravenous 
injection  of  salvarsan  and  the  supplementary  coiu-se  of  mercury  are 
repeated. 

Skill  in  the  diagnosis  of  syphilitic  manifestations  is  of  the  utmost 
importance  to  dentists  and  oral  surgeons  for  their  own  protection  and 
the  welfare  of  their  patients,  both  syphilitic  and  non-syphilitic.  They 
may  or  may  not  undertake  the  treatment  of  these  cases,  but  the 
menace  of  the  presence  of  syphilis  cannot  be  avoided  except  by  care 
and  intelligent  understanding  of  the  symptoms. 


CHANCROID. 

Chancroid  or  soft  chancre  is  a  specific  local,  contagious,  auto- 
infectious  venereal  ulcer.  Its  nature  is  quite  unlike  the  hard  or 
syphilitic  chancre  with  which  it  is  sometimes  confused. 


128  INFECTIOUS  DISEASES 

Etiology. — Chancroid  is  caused  by  the  streptobacillus  of  Ducrey, 
akhoiigh  it  is  often  a  mixed  infection,  and  microscopic  examination  may 
show  pyogenic  and  other  bacteria.  It  is  almost  never  acquired  except 
in  sexual  intercourse.  There  must  be  an  abrasion  of  the  skin  at  the 
point  of  infection  in  order  to  transmit  the  affection,  except  in  cases 
where  many  hours  of  constant  contact  make  it  possible. 

Symptoms. — The  lesion  is  local,  and  is  not  accompanied  by  systemic 
reaction  or  infection.  After  a  single  ulcer  upon  the  male  or  female 
genitals  others  soon  appear.  These  may  spread  by  contact  or  exten- 
sion to  other  regions.  The  anus,  thighs,  abdomen,  or  any  other  part 
of  the  body  that  the  infection  reaches  may  become  infected. 

The  period  of  incubation  is  usually  from  three  to  five  days.  Occa- 
sionally it  may  be  as  long  as  ten  days  when  actual  infection  is  delayed. 

Chancroid,  when  uncomplicated,  is  a  round  ulcer  with  sharply 
defined,  often  undermined  and  everted  edges.  It  is  surrounded  by  an 
inflamed  base  that  is  not  indurated.  In  color  it  is  grayish  yellow, 
with  abundant  purulent  secretion. 

The  Mixed  Sore. — ]\Iuch  difficulty  in  diagnosis  arises  when  chancroid 
and  syphilis  occur  at  the  same  time.  The  chancroid  may  be  evident, 
and  the  syphilis  not  so  much.  The  natural  result  of  such  a  condition 
might  easily  be  an  error  in  diagnosis,  with  serious  consequences. 

Bubo. — Bubo  follows  chancroid,  according  to  Keyes,  in  about  one 
out  of  every  three  cases.  This  inflammatory  condition  of  the  inguinal 
glands  may  gradually  disappear  by  resolution,  or  suppuration  may  take 
place.     The  pus  from  these  undent  buboes  is  auto-inoculable. 

Diagnosis. — Chancroid  is  diagnosticated  by  recognition  of  its  bacillus 
with  the  microscope,  and  by  auto-inoculation  if  the  history  and  symp- 
toms are  not  sufficiently  clear.  Its  differentiation  from  chancre  may 
be  determined  bv  the  clinical  features  set  forth  in  the  table  on  page 
117. 

Prognosis. — Simple,  uncomplicated  chancroid  is  controlled  with 
comparative  ease.  When,  however,  phagedena  occurs  through  mixed 
streptococcus  infection,  the  prognosis  is  less  favorable,  and  cases  have 
been  reported  with  destruction  of  the  urethra,  followed  by  extension 
of  the  disease  up  the  penis  until  the  mucous  membrane  of  the  bladder 
was  attacked,  and  death  followed.  Fortunately  such  cases  are  very 
rare. 

Treatment. — Cauterization  in  the  treatment  of  newly  formed  chan- 
croids is  useful  if  all  the  sores  be  thoroughly  treated.  Following  the 
cauterizing  agent,  the  sore  is  cleaned  with  dioxogen,  and  a  soothing 
dressing  applied. 

Recently  the  tendency  has  been  to  treat  chancroid  as  any  other  local 
infection  would  be  treated,  by  the  use  of  suitable  bactericidal  agent 
and  mildly  antiseptic  dusting  powder,  without  resort  to  cauterization 
by  silver  nitrate,  nitric  and  carbolic  acid,  and  similar  agents.  Effort 
should  be  made  to  prevent  extension  to  the  groin  by  keeping  the  patient 
quiet  and  making  hot  applications  the  moment  inflammatory  symptoms 
rein  this  gion  are  noted. 


ACTINOMYCOSIS  129 


ACTINOMYCOSIS. 


Actinomycosis  is  a  chronic  infectious  disease,  characterized  by 
inflammatory  reaction  of  the  tissues,  with  a  tendency  to  the  formation 
of  suppurative  foci ;  it  affects  man  and  domestic  animals,  and  is  caused 
])y  the  .Streptothrix  actinomycosis  or  ray  fungus. 

On  account  of  the  frequency  with  which  cattle  are  affected  by  lumpy 
jaw,  an  attempt  has  been  made  to  distinguish  actinomycosis  bo  vis  from 
that  which  affects  man ;  but  this  distinction  does  not  seem  to  hold,  as 
the  organisms  are  practically  identical. 

Etiology. — Actinomyces  are  found  upon  oat  seed,  the  rust-covered 
straws  of  wheat  and  other  grains. 

It  has  commonly  been  accepted  that  infection  must  occur  through 
some  such  medium,  but  as  the  fungus  is  also  found  upon  vegetable 
substances,  it  has  been  suggested  that  salads  and  uncooked  vegetables 
may  be  responsible  for  infection. 

The  suggestion  of  recent  writers,  notably  Stengel,  that  the  organism 
is  a  rigid  anaerobe  and  grows,  only  at  body  temperature,  tends  to  dis- 
prove these  views.  He  says:  "It  is  likely  that  the  actinomyces  is  a 
normal  inhabitant  of  the  mouth  and  gastro-intestinal  tract,  and  that 
it  is  always  derived  from  these  sources.  Carious  teeth  and  lesions  of 
the  mucous  membranes  play  a  part  in  the  etiology." 

The  presence  of  portions  of  straw,  the  husk  of  grains,  and  similar 
substances  that  have  been  reported  as  being  found  within  the  suppura- 
tive foci  of  this  disease,  lend  color  to  the  former  theory;  while  the  great 
frequency  with  which  the  disease  is  found  to  have  its  beginning  in  the 
mouth  and  associated  structures  gives  clinical  support  to  the  latter. 

Coplin^  states  that  studies  of  the  last  few  years  appear  to  have 
established  that  "actinomycosis  may  be  due  to  any  one  of  several 
closely  related  parasites." 

Wright^  and  other  investigators  maintain  that  the  independence 
of  the  true  actinomyces  has  been  established. 

Pathology. — The  actinomyces  cause  round-celled  infiltration  and 
proliferation  in  the  connective  tissues  surrounding  the  parasite.  This 
may  lead  on  to  softening,  necrosis,  and  suppuration.  In  man  the 
gums,  cheeks,  and  floor  of  the  mouth,  as  well  as  the  lungs,  intestines, 
and  other  internal  organs,  may  be  affected.  There  seems  to  be  an 
alternate  tendency  to  suppuration  and  repair,  which  is  accompanied  by 
cicatrization  with  marked  induration  of  the  tissues.  In  the  jaw-bone 
there  is  progressive  decalcification  of  the  osseous  structures,  with 
tendency  to  the  formation  of  nodular  masses  in  the  surrounding  soft 
tissue.  Metastases  sometimes  occur  through  penetration  of  the  blood- 
vessels or  lymph  channels,  and  thus  any  organ  of  the  body  may  become 
involved. 


1  Manual  of  Pathology,  p.  167. 

2  Jour.  Med.  Research,  May,  1905.     Stengel:  Text-book  of  Pathology,  pp.  298,  299. 

9 


130 


INFECTIOUS  DISEASES 


Symptoms. — As  a  rule,  actinomycosis  becomes  chronic  and  continues 
over  periods  varying  from  months  to  years.  According  to  Coplin,' 
in  over  50  per  cent,  of  the  cases  in  man  the  lesion  is  located  in  the 
tissues  of  the  head  and  neck.  Poncet  Berard  suggested  division  of 
actinomycotic  affections  into  foiu-  regions:  (1)  Cervical-facial;  (2) 
thoracic;  (3)  abdominal;  and  (4)  cutaneous.  Its  appearance  in  other 
regions,  such  as  the  brain,  spinal  coliunn,  genito- urinary  tract,  and  in 
the  various  special  organs  is  chiefly  accepted  as  an  indication  of  com- 
plications by  metastatic  extension. 

When  the  face  and  the  neck  are  affected  the  point  of  beginning 
usually  appears  in  the  vicinity  of  a  diseased  tooth.  There  is  swelling 
upon  the  affected  side  over  and  around  the  jaw,  sometimes  including 
the  adjacent  glands  of  the  neck.     A  number  of  fistulous  openings 


Fig.  59. — Fistulce  of  actinomycosis. 

often  discharge  from  the  point  of  suppuration  (Fig.  59),  and  in  long- 
standing cases  these  are  surrounded  by  firm  nodular  masses  (Fig.  60) 
which  represent  the  sites  of  previous  inflammatory  foci.  The  char- 
acteristic discharge  contains  sulphur-like  granules,  which  have  some- 
times been  likened  to  mustard  seeds  in  appearance.  When  these  are 
spread  upon  a  microscopic  slide,  the  typical  ray  shape  of  the  fungus 
becomes  noticeable  (Fig.  61). 

Pain. — Pain  may  or  may  not  be  an  important  s^-mptom.  ]\Iany 
times  the  condition  is  practically  painless.  In  other  cases  chronic 
pain  may  be  complained  of  through  pressure  or  involvement  of  nerve 
structures.     Fever  is  seldom  observed.     In  view  of  the  often  extensive 

1  Manual  of  Pathology,  p.  169. 


ACTINOMYCOSIS 


131 


and  serious  character  of  the  lesions,  the  general  symptoms  are  com- 
paratively slight  if  at  all  noticeahle. 


Fig.   60. — Actinomycosis  of  cheek,  showing  nodular  masses.      (Illich.) 


Fig.  61. — Actinomyces. 


These  symptoms  are  of  course  subject  to  complications  such  as 
may  arise  in  the  course  of  any  inflammatory  process. 


132  INFECTIOUS  DISEASES 

Trismus. — ^Trismus  is  a  quite  common  s\Tnptom  in  cases  of  actino- 
mycosis which  affect  the  jaws,  because  the  inflammatory  infiltration 
quickly  involves  the  muscles  of  mastication.  JLven  from  the  neck  and 
cheek  the  masseter,  temporal,  and  pterygoid  muscles  may  be  affected. 
As  the  disease  extends,  the  hardened  masses  become  fixed,  and  the 
difficulty  of  jaw  movement  is  increased. 

Diagnosis. — The  description  of  the  s^Tnptoms  of  actinomycosis 
might  lead  to  the  expectation  that  the  disease  would  be  easily  recog- 
nized, but,  as  a  matter  of  fact,  clinical  experience  often  demonstrates 
that  there  is  much  difficulty  in  differentiating  its  symptoms  from  those 
of  a  number  of  other  affections.  The  swelling  and  extensive  indura- 
tion in  the  region  of  the  malar  bone  and  cheek,  when  fistulse  are  absent, 
are  sometimes  not  easily  distinguished  from  malignant  growths  or  even 
gumma.  Of  course,  time  will  usually  demonstrate  the  tendency  to 
break  down  and  the  formation  of  pus;  but  time  in  dealing  with  neo- 
plasms in  that  region  is  a  matter  of  first  importance.  ^Microscopic 
sections  of  tissue  in  these  cases  must  be  made  to  complete  differentia- 
tion. Sometimes  the  greater  density  of  the  actinomycotic  mass  and 
the  history  of  the  case  may  serve  to  give  reasonable  assurance  of  its 
character. 

Necrosis  of  the  jaws,  chronic  dento-alveolar  abscesses,  especially 
when  there  has  been  an  extensive  diffuse  suppurative  periostitis,  or  if 
a  number  of  chronic  dento-alveolar  abscesses  are  involved,  a  series  of 
fistulse  discharging  through  the  neck  and  the  induration  from  repeated 
acute  inflammations,  in  chronic  cases  of  long  standing,  may  produce 
conditions  the  external  appearance  of  which  it  is  difficult  to  distinguish 
from  actinomycosis.  Tubercular  affections  in  the  same  region  are  also 
occasionally  of  such  character  as  to  make  their  identification  difficult, 
except  by  determining  the  presence  of  tubercle  bacilli.  If  the  yellow 
granules  which  so  readily  display  the  ray  fungus  were  constantly 
present  in  the  pus,  the  difficulty  ^^■ould  not  be  so  great;  but  they  do  not 
appear  to  be  constant  in  the  discharge  at  all  stages;  doubtless  because 
there  is  so  frequently  a  mixed  infection  in  ^^'hich  the  pathogenic  micro- 
organisms largely  supersede  the  actinomyces,  and  under  these  condi- 
tions render  difficult  their  recognition. 

Widal^  has  applied  the  principles  of  his  well-known  agglutination 
test  for  typhoid  to  secure  a  similar  reaction  in  actinomycosis,  and  to 
ascertain  whether  the  spores  of  Sporotrichum  beurmanni,  which,  in 
contact  with  serum  from  subjects  with  sporotrichosis,  give  rise  to 
intense  agglutinations  at  1  to  400,  1  to  500,  and  o^•er,  might  not  also 
be  agglutinated  by  the  serum  from  individuals  with  actinomycosis 
(coagglutination) . 

"This  hj'pothesis  was  verified  in  practice,  S  patients  of  different  ages 
and  with  different  types  of  actinomycosis,  all  exhibited  manifest  coag- 
glutination on  contact  with  the  spores  of  the  sporotrichum,  varying 

1  Jour,  de  Chirurg.,  July,  1910. 


ACTINOMYCOSIS  133 

from  1  to  50  to  1  to  51.  Moreover,  they  all  showed  well-marked 
cofixation.  ^Vhen  this  phenomenon  is  obtained  it  shows  we  are  dealing 
with  a  mycosis  belonging  to  the  same  family  as  the  actinomycosis; 
once  this  is  established,  the  clinical  course  should  enable  actinomycosis 
to  be  differentiated  from  other  mycoses  caused  by  the  same  family." 

Prognosis. — The  prognosis  is  good  when  the  foci  of  infection  can  be 
completely  removed  and  the  surrounding  areas  properly  treated. 

Treatment. — The  surgical  treatment  consists  of  the  removal  of  the 
diseased  tissue  as  effectively  as  possible.  The  extensive  resections  of 
the  jaw,  \Ahich  ^^■ere  formerly  thought  necessar}',  are  now  practically 
discarded.  Removal  of  a  portion  of  the  jaw-bone  and  the  thorough 
curettement  of  the  diseased  surface  with  a  bone  curette,  as  in  cases 
of  caries  and  necrosis  of  bone  from  other  causes,  is  sufficient.  The 
excision  of  the  fistulous  tracts  and  thorough  destruction  of  the  inflam- 
matory foci,  with  removal  of  the  indurated  tissue  masses,  is  found  to 
be  sufficient  when  supplemented  by  proper  local  internal  treatment. 
Potassium  iodide  taken  internally,  and  the  direct  application  of  iodin 
to  the  "\A'ound  surfaces,  formerly  gave  the  most  satisfactory  results. 
Experiments  of  the  Agricultural  Department  of  the  University  of 
^Yisconsin  showed  that  when  grains  before  planting  were  washed  in 
sulphate  of  copper,  there  was  freedom  from  rust.  The  same  remedy 
was  applied  in  the  treatment  of  actinomycosis  by  Bevan,  of  Chicago, 
and  others.  The  internal  administration  of  sulphate  of  copper  and 
its  application  directly  to  the  lesion  were  found  to  give  the  most  satis- 
factory results.  This  method  of  treatment  was  first  reported  to  the 
dental  profession  by  Dr.  T.  W.  Brophy,  of  Chicago,  with  the  description 
of  some  interesting  cases  and  results. 

A  suggestion  from  the  author's  experience  may  perhaps  simplify 
these  cases  to  those  unfamiliar  with  their  appearance  and  treatment. 
The  all-important  differentiation  of  neoplasm  by  the  microscope  gives 
the  operator  a  considerable  measure  of  freedom.  The  use  of  potas- 
sium iodide  internally  and  local  applications  of  tincture  of  iodin  would 
be  beneficial  rather  than  harmful,  even  though  the  disease  chanced 
to  be-sj-philis  or  even  tuberculosis,  and  thorough  surgical  removal  of 
diseased  tissue  ought  to  facilitate  recovery  in  any  one  of  several  patho- 
logical aft'ections  with  ^^■hich  this  disease  might  probably  be  confused. 
Continued  observation  of  the  cases;  examination  of  the  contents  of  the 
fistulous  tracts;  microscopic  study  of  the  diseased  tissue;  the  applica- 
tion of  diagnostic  methods  which  would  be  likely  to  lead  to  the  detec- 
tion or  exclusion  of  other  diseases  if  the  s\Tnptoms  of  actinomycosis 
were  not  sufficiently  positive  to  be  depended  upon;  might  one  or  all 
be  relied  upon  for  differentiation  during  the  progress  of  the  disease; 
and  in  the  meantime  the  treatment  would  be  helpful  rather  than 
harmful. 

Stengel^  describes  a  case  of  actinomycosis  of  the  cheek,  which  is  of 

1  Med.  Record,  June  4,  1910. 


134  INFECTIOUS  DISEASES 

particular  interest  because  of  the  definite  recognition  of  its  point  of 
origin,  as  well  as  for  his  description  of  s\'niptoms  and  treatment: 

"A  week  later"  (than  the  injury,  which  occurred  Xovember  1) 
"the  patient  felt  a  slight  elevation  and  hardness  at  the  spot  of  injury. 
His  first  impression  of  it  was  a  swelling  of  the  mouth  of  Steno's  duct, 
such  as  occasionally  occurs.  The  induration,  however,  remained  and 
seemed  to  be  increasing  during  the  next  three  weeks.  On  December 
3  the  mother  discovered  a  slight  purplish  spot  on  the  outside  of  the 
cheek  opposite  the  growth  within,  and  on  examination  the  whole  cheek 
was  found  occupied  by  a  resilient  mass  that  seemed  attached  to  the 
skin  on  the  outside  and  the  mucosa  within.  J.  W.  ^Yhite  advised 
incision  on  the  inner  side.  At  operation  the  mass  was  found  to  be 
uniform,  pinkish,  with  no  sign  of  breaking  down  within.  Portions 
were  found  to  be  made  up  of  round  cells,  which  suggested  an  inflam- 
matory process  or  sarcoma.  No  actinomyces  were  discovered. 
Though  drainage  with  gauze  was  maintained  on  the  inside,  the  growth 
extended  out,  and  soon  an  abscess-like  projection  formed  at  the  side 
of  the  purplish  area.  The  danger  of  extensive  involvement  of  the  skin 
now  led  to  an  incision  where  the  growth  pointed  externally.  A  small 
amount  of  broken-down  yellowish  material  was  obtained  and  portions 
of  the  growth  were  removed.  In  the  latter,  after  a  number  of  sections 
were  studied,  actinomyces  were  detected.  The  patient  had  in  the 
meantime  been  given  increasing  doses  of  KI  on  account  of  the  sus- 
picions of  actinomycosis  after  the  first  appearance  of  the  purplish 
discoloration  and  external  projection.  Another  abscess-like  formation 
developed  on  January  15,  and  was  opened  January  18.  Increasing 
doses  of  KI,  up  to  60  grains  daily,  were  given  without  materially  influ- 
encing the  progress.  At  this  tune,  on  the  suggestion  of  A.  C.  Wood, 
diluted  tincture  of  iodin  was  used  in  each  of  the  incisions  or  sinuses. 
Almost  immediately  there  was  a  manifest  improvement,  and  within 
a  fortnight  the  whole  infiltration  had  resolved.  Subsequently  the 
incisions  healed.  The  patient  never  suffered  any  recurrence,  and  is 
now  in  good  health." 

GLANDERS. 

Glanders  is  an  infectious  and  contagious  disease  due  to  a  specific 
bacillus,  which  chiefly  aftects  horses  and  asses,  though  it  may  be  com- 
municated to  other  animals  and  to  man. 

Etiology. — Glanders  infection  is  caused  by  the  Bacillus  mallei. 
"SMien  involving  only  the  skin  and  adjacent  glands  it  is  called  farcy. 
^Yhen  the  mucous  membrane  is  affected,  the  condition  is  termed 
glanders.  Usually  it  is  communicated  to  man  from  the  horse,  although 
it  affects  a  considerable  variety  of  domestic  and  wild  animals.  The 
bacilli  commonly  gain  entrance  through  some  abraded  or  wounded 
surface  in  the  skin  or  mucous  membrane. 

Pathology. — It  first  appears  in  the  form  of  a  small  nodule  which 
contains  the  almost  pure  leukoc^tic  infiltrate,  a  few  giant  cells,  and  the 
characteristic  bacilli.     This  increases  and  produces  an  ulcer,  which 


GLANDERS  135 

usually  results  in  a  series  of  ulcers  that  may  or  may  not  become  con- 
fluent. Extension  through  the  lymphatic  system  sometimes  leads  to 
a  chronic  condition.  In  acute  cases  multiple  abscesses  throughout  the 
body  may  cause  death  from  exhaustion  and  toxemia. 

Symptoms. — Glanders  may  be  acute  or  chronic.  Farcy  also  appears 
in  both  acute  and  chronic  forms,  although  according  to  some  authori- 
ties farcy  is  applied  to  a  chronic  form  of  this  affection ;  but  this  some- 
what arbitrary  classification  does  not  seem  to  be  borne  out  by  clinical 
manifestations. 

In  acute  glanders  there  is  a  period  of  incubation  of  approximately 
three  or  four  days.  Two  recorded  cases,  in  which  the  symptoms 
appeared  in  six  days  and  six  weeks  respectively,  serve  to  show  the  wide 
limits  within  which  the  incubation  period  varies. 

Swelling,  redness,  and  the  usual  signs  of  lymphatic  involvement 
appear  at  the  point  of  inoculation.  The  mucous  membranes  of  the 
nose  are  attacked  in  the  course  of  a  few  days.  When  the  nodules  which 
form  there  break  down  there  is  a  discharge  of  mucopus.  The  nose  and 
lymph  nodes  of  the  neck  may.become  considerably  swollen,  and  there  is 
usually  an  eruption  of  papules  and  pustules  upon  the  face. 

The  duration  of  the  disease  is  about  ten  days,  and  it  terminates 
fatally,  usually  from  involvement  of  the  lungs. 

In  chronic  glanders  the  chief  symptoms  are  those  of  chronic  nasal 
catarrh,  with  ulcers  upon  the  surface  of  the  mucous  membrane. 

In  acute  farcy  the  skin  is  affected  by  intense  local  inflammation. 
Nodules  called  farcy  buds  are  felt  along  the  course  of  the  lymphatics, 
because  of  their  involvement.  Suppuration  may  ensue  as  with  other 
lymphatic  affections.  Papular  eruption  sometimes  appears  upon  the 
skin.  Fever  occurs,  resembling  that  of  typhoid  or  septic  infection. 
Pains  and  swelling  in  the  joints  are  often  a  marked  feature.  Prognosis 
in  these  cases  is  almost  as  discouraging  as  that  of  acute  glanders,  death 
usually  ensuing  in  the  course  of  tw^o  weeks. 

In  chronic  farcy  the  lymphatics  are  not  specially  involved;  but 
nodular  tumors  form  in  the  extremities.  These  may  break  down  and 
give  rise  to  abscesses  or  ulcers. 

Diagnosis. — One  method  of  diagnosis  is  made  by  the  peritoneal 
inoculation  of  male  guinea-pigs  with  the  suspected  discharges  according 
to  Strauss'  test.  If  the  Bacilli  mallei  are  present  there  will  be  swelling 
of  the  testes,  followed  by  swelling  and  ulceration  of  the  scrotum  before 
the  fifth  or  sixth  day. 

Mallein  is  prepared  from  the  bacilli  and  used  for  diagnostic  purposes 
in  the  same  manner  as  tuberculin  for  tuberculosis.^ 

The  Agglutination  Test. — This  procedure  for  the  diagnosis  of  glan- 
ders is  based  upon  the  phenomena  of  agglutination  and  precipitation. 
When  the  blood  serum  of  a  horse  affected  with  glanders  is  brought 
into  contact  with  certain  cultures  of  either  live  or  dead  bacteria, 
which  are  the  specific  cause  of  the  disease,  a  clumping  or  formation 

'  Coplin:  Manual  of  Pathology,  p.  161. 


136  INFECTIOUS  DISEASES 

of  the  flocculent  masses  of  the  organisms  will  take  place.  The  glanders 
germs  which  before  the  addition  of  glandular  horse  serum  are  scattered 
singly  through  the  liquid,  when  placed  under  the  influence  of  glandular 
seriun  become  so  changed  that  they  gradually  adhere  one  to  another 
and  form  small  flakes,  which  settle  at  the  bottom  of  the  container,  or, 
in  other  words,  precipitate.  These  bacteria  are  taken  from  the  culture, 
killed  by  heating,  and  placed  in  suspension  in  a  germicidal  or  preserving 
fluid,  thus  forming  an  emulsion  or  suspension  of  dead  glandular  germs. 
To  a  given  amount  of  this  suspension  of  glandular  organisms,  or  test 
fluid,  given  amounts  of  glandular  horse  serum  are  added.  Serum  from 
an  animal  affected  with  glanders  causes  the  dead  suspended  germs  to 
agglutinate  or  clump,  and  flocculent  masses  of  the  dead  germs  are 
formed  throughout  the  suspension  fluid.  This  is  called  a  positive 
reaction.  When  the  reaction  or  agglutination  is  complete,  the  floccu- 
lent masses  of  agglutinated  bacteria  will  have  settled  at  the  bottom  of 
the  tube. 

To  facilitate  making  this  test  the  department  of  experimental  medi- 
cine of  the  Parke-Davis  Laboratory  has  devised  a  simplified  apparatus, 
with  control  tubes,  containing  the  test  fluid  to  which  no  serum  has 
been  added;  and  other  tubes  which  contains  respectively  1  part  of 
serum  to  200,  500,  800,  and  1200  parts  of  test  fluid. 

The  conclusions  from  these  tests  are  that  all  horses  whose  blood 
agglutinates  in  solutions  of  1  to  1000  or  higher  should  be  destroyed; 
all  those  that  show  agglutination  as  low  as  1  to  500,  if  they  show 
symptoms  of  glanders,  should  be  destroyed;  below  that  they  may  be 
considered  safe. 

Bernstein  and  Carling^  refer  to  5  cases  of  glanders  that  were  admitted 
to  the  Westminster  Hospital  in  London,  and  state  that  reports  which 
show  glanders  to  be  a  rare  affection  are  misleading.  They  hold  that 
it  is  much  more  common  than  is  generally  supposed,  so  much  so  that 
"whenever  there  is  a  chronic  inflammatory  lesion  of  the  oral  or  nasal 
mucosa,  or  an  inflammatory  mass  in  the  subcutaneous  or  muscular 
tissue,  if  it  is  known  that  the  patient  has  been  brought  into  contact  with 
sick  horses,  the  diagnostician  should  be  on  the  alert  for  glanders." 

Treatment. — If  seen  early,  cauterization  or  excision  of  the  lesion  may 
be  helpful.  The  enlarged  glands  or  farcy  buds  may  be  opened  and 
disinfected. 

Beyond  measures  of  this  character  and  treatment  to  relieve  the 
symptoms  there  seem  to  be  no  known  satisfactory  therapeutic  methods 
with  which  to  combat  this  disease. 

ANTHRAX,  WOOLSORTERS'  DISEASE,  MALIGNANT  PUSTULE, 
SPLENIC  FEVER. 

Anthrax  is  an  acute  infectious  disease,  which,  although  other  animals 
may  be  affected,  attacks  sheep  and  cattle  most  frequently,  and  from 

1  British  Med.  Jour.,  February  6,  1909. 


ANTHRAX,  WOOLSORTERS'  DISEASE  137 

these  is  often  communicated  directly  or  indirectly  to  man.  Dogs, 
cats,  birds,  and  cold-blooded  animals  appear  to  be  quite  unmune. 

Etiology.— It  is  caused  by  anthrax  bacillus,  a  more  than  ordinarily 
resistant,  readily  spore-forming  bacillus.  These  bacilli  will  withstand 
a  boiling  temperature  of  water  for  several  minutes;  to  destroy  them 
requires  prolonged  immersion  in  a  solution  as  strong  as  5  per  cent, 
carbolic  acid;  they  are  not  killed  by  the  gastric  juices,  and  the  spores 
are  believed  to  be  capable  of  living  for  a  long  period  of  time  outside  of 
the  body.  Those  who  handle  hides  are  frequently  infected  on  the 
hands  and  face,  as  are  butchers,  through  contaminated  meat,  and 
woolsorters  by  inhalation  of  infection. 

Symptoms. — A  swelling  develops  at  the  site  of  the  infection,  which 
is  intensely  inflammatory,  surrounded  by  slight  bullous  vesicles  and 
usually  attended  with  considerable  edema.  A  sanious  liquid  is  dis- 
charged when  erosion  of  the  surface  takes  place,  and  there  may  be 
more  or  less  pus  formation.  Bacilli  are  found  in  all  of  the  local  lesions 
and  are  eventually  carried  into  the  blood,  and  thus  reach  the  spleen, 
liver,  kidneys,  lungs,  and  other  organs.  They  are  also  discharged 
from  the  body  in  the  stools  and  urine,  and  thus  give  opportunity  for 
the  infection  of  other  animals.  Infection  through  the  gastro- intestinal 
tract  causes  hemorrhagic  extravasation,  ulceration  of  the  mucous 
surfaces,  and  profuse  diarrhea  with  bloody  discharges. 

The  postules  which  form  on  the  hands,  arms,  face,  and  neck  in  the 
external  variety  of  this  disease  usually  follow  an  incubation  period  of 
two  or  three  days.  The  characteristic  malignant  anthrax  edema  in 
many  cases  follows  in  the  course  of  a  few  hours.  Death  sometimes 
occurs  within  three  or  four  days. 

Intestinal  anthrax  is  ushered  in  by  a  chill,  followed  by  diarrhea,  fever, 
and  other  evidences  of  acute  infection. 

The  disease  in  the  respiratory  tract  is  accompanied  by  severe  symp- 
toms, of  which  chills,  pains  in  the  chest,  back,  and  legs,  respiratory 
difficulties,  fever,  and  cough  are  marked  indications.  Death  sometimes 
occurs  within  thirty-six  hours  of  the  onset  of  the  disease. 

Brewer^  reports  the  mortality  in  cases  in  which  infection  has 
occurred  in  the  extremities  at  less  than  5  per  cent.,  but  when  the 
lesion  is  on  the  neck  or  face  the  mortality  rises  to  about  30  per  cent., 
with  a  much  higher  mortality  in  the  internal  cases. 

Diagnosis.- — Although  the  symptoms  may  sometimes  be  confusing, 
the  diagnosis  is  readily  made  by  recognition  of  the  bacillus. 

Prognosis. — In  cases  of  external  anthrax  the  mortality  does  not 
usually  exceed  5  per  cent.  When  the  lesion  is  situated  on  the  neck 
or  face  the  death-rate  is  about  30  per  cent.;  in  internal  anthrax  it  is 
much  higher. 

Treatment. — ^Wide  excision  of  the  primary  lesion  should  be  made 
without  an  instant's  avoidable  delay.     Adjacent  lymph  nodes  that 

1  Text-book  of  Surgery,  3d  ed.,  1915,  p.  48. 


138 


INFECTIOUS  DISEASES 


may  be  involved  should  also  be  removed,  and  the  wound  dismfected 
by  some  powerful  germicide.  Cauterization  is  sometimes  effective, 
but  not  so  much  so  as  excision.  The  advocates  of  less  radical  methods 
urge  that  the  cauterization  is  equally  effective,  and  that  it  does  not 
give  opportunity  for  fatal  general  infection,  ^^■hich  they  believe  is  likely 
to  follow  in  malignant  cases  when  the  bloodvessels  are  opened  up  by 
the  incisions.  Defects  of  the  lips  which  are  sometimes  occasioned  by 
the  scars  of  these  lesions  may  be  remedied,  if  necessary,  by  plastic 
operations  after  recovery  is  complete.  In  other  respects  the  disease 
should  be  treated  as  a  toxemia,  and  all  the  natural  forces  should  be 
stimulated  by  activity  and  nourished  to  the  highest  possible  degree, 
to  increase  resistance  to  infection. 

The  following  table  by  Royer  and  Holmes^  gives  a  comprehensive 
description  of  the  manner  of  infection,  and  the  results  of  treatment : 


Occupation. 

Location  of  lesion. 

Day  of  disease. 

Treatment. 

Results. 

Farmer 

Forearm  (left) 

Eighth 

Surgical  and  phenol 
injection 

Cured. 

Hide  sorter 

Right  neck 

Third 

Serum  only 

Died. 

Hide  scraper 

Right  ring  finger 

Fourteenth 

Local  antiseptic 

Cured. 

Teamster 

Right  forearm 

Third 

Surgical  and 
antiseptic 

Died. 

Morocco  worker 

Neck  (left) 

■  Fifth 

Serum  and  surgical 

Cured. 

Hair  sorter 

Left  neck 

Third 

Serum  and  surgical 

Cured. 

Hide  sorter 

Lower  lip  (right) 

Fifth 

Surgical 

Cured, 

Hide  stacker 

Forehead  (right) 

Twelfth 

Serum  and  surgical 

Cured. 

Hide  stacker 

Face  (left  side) 

Twenty-first 

Serum  only 

Cured. 

Stevedore 

Neck  (left) 

Fourth 

Senmi  and  late 
surgical 

Died. 

Hair  sorter 

Neck  (right) 

Fourth 

Serum  only 

Cured. 

Hair  washer 

Right  cheek 

Fourth 

Senmi  only 

Cured. 

Hair  comber 

Right  cheek 

Fifth 

Serum  and  surgical 

Cured, 

Clerk  and  hair 

Chin  (left  side) 

Third 

Serum  and  surgical 

Cured, 

dealer 

Hair  spinner 

Right  cheek 

Second 

Serum  and  surgical 

Cured, 

The  conclusions  of  these  authors  with  regard  to  treatment  are  also 
of  interest: 

"Only  general  conclusions  regarding  the  treatment  may  be  drawn 
from  these  cases,  and  these  chiefly  from  individual  cases.  Serum 
treatment  alone  in  certain  cases  seems  to  be  curative.  Serum  com- 
bined with  excision  and  cauterization  with  bichloride  would  seem  to 
give  best  results  in  severe  cases,  while  excision  and  cauterization  ^^■ill 
undoubtedly  cure  many." 

Two  cases  leported  by  Clarke^  illustrate  important  features.  These 
"  occurred  simultaneously  in  a  farmer  and  a  butcher's  assistant  respec- 
tively, who  had  four  days  previously  killed  and  dressed  a  diseased  bull, 
apparently  neither  having  the  least  idea  of  the  cause  of  the  animal's 
illness.     Four  days  after  each  noticed  a  pimple  on  his  arm. 

"  The  farmer,  aged  twenty-eight  years,  called  with  a  sore.     The  site 


1  Therap.  Gaz.,  January,  1908. 

2  Lancet.  February  29,  1908. 


LEPROSY,  LEPRA,  ELEPHANTIASIS  GRECORUM  139 

was  the  upper  antero-external  surface  of  the  left  forearm ;  it  was  about 
one  inch  in  diameter,  with  a  depressed  center  and  a  ring  of  low  vesicles 
around;  the  central  depression  was  purplish  red  but  not  black — 
it  could  not  have  been  described  as  a  typical  pustule.  There  was  no 
edema  and  no  pain.  The  axillary  glands  were  enlarged.  The  tem- 
perature was  100.4°  F.,  and  he  complained  of  frontal  headache;  his 
tongue  was  furred  and  there  was  some  general  constitutional  disturb- 
ance. This  patient  had  attempted  no  local  treatment.  Slides  were 
promptly  prepared  from  the  vesicles  and  stained.  A  few  large  bacilli 
were  seen,  occurring  singly  and  in  chains.  That  night  the  pustule  was 
excised  with  a  margin  of  sound  skin,  the  subjacent  fatty  tissue  being 
removed  at  the  same  time;  pure  carbolic  was  then  applied  and  the 
wound  dressed  with  sal  alembroth  gauze  soaked  in  bichloride  lotion. 

"In  Case  2  the  lesion  was  on  the  back  of  the  wrist  and  was  only 
the  size  of  a  dime.  The  pustule  was  far  more  typical;  there  was  a 
dark  central  eschar.  There  had  been  considerable  pain  in  the  sore, 
coming  on  a  day  or  so  after  he  first  noticed  the  pimple,  which  had  led 
the  patient  to  poultice  it.  He  had  no  constitutional  symptoms  and 
had  continued  at  his  work.  When  seen  the  wrist  was  slightly  edema- 
tous and  there  was  some  redness  around  the  sore;  the  axillary  glands 
were  enlarged.  In  this  case  the  pustule  was  drawn  forward  and  frozen 
w'ith  ethyl  chloride;  its  base  transfixed  and  the  sore  w'as  excised.  The 
after-treatment  was  the  same.     Both  healed  up  well." 

LEPROSY,  LEPRA,  ELEPHANTIASIS  GRECORUM. 

This  is  a  chronic  infectious  disease  caused  by  the  Bacillus  leprae. 

Etiology. — The  bacillus  of  leprosy,  recognized  as  the  cause  of  the 
disease,  has  been  demonstrated  in  the  blood,  in  the  leprous  lesions, 
and  in  the  nasal  mucus,  without  regard  to  the  presence  or  absence  of 
ulcerative  conditions  in  the  nose. 

The  disease  has  been  transmitted  to  a  condemned  criminal  by  direct 
inoculation,  and  there  has  been  much  experimentation  without  abso- 
lutely definite  results  in  the  direction  of  attempting  to  inoculate  animals 
with  leprous  tissue. 

How  far  the  conditions  of  countries  and  localities  may  influence 
the  frequency  of  the  disease,  and  whether  fish  or  certain  other  articles 
of  diet,  to  which  attention  has  been  called,  may  be  regarded  as  factors 
in  causation  or  predisposition,  is  not  clear  at  the  present  time.  Inti- 
mate association  for  a  considerable  period  seems  to  be  necessary  to 
transmit  the  disease.  It  is  believed  to  be  hereditary,  but  whether  it  is 
the  disease  or  the  predisposition  that  is  inherited  is  still  a  matter  of 
doubt. 

Symptoms. — It  appears  in  two  forms,  the  tubercular  and  the  anes- 
thetic. 

In  the  tubercular  form  ar^e  found  the  characteristic  skin  lesions 
which  appear  in  the  early  stages,  and  which  have  a  reddish  color, 


140 


INFECTIOUS  DISEASES 


with  slight  inflammatory  reaction  in  the  beginning.  The  latter 
lose  the  redness  of  color,  and  as  the  disease  progresses  may  show 
tendency  to  break  down  and  form  ulcerations  which  heal  slowly  or 
become  con\'erted  into  fibrous,  cicatricial  masses  that  cause  marked 
and  unsightly  deformities.  The  mucous  membranes  and  internal 
organs  may  also  be  involved. 


Fig.  62  Fig.  63 

Fig.  62. — Case  I.  Leprosy  of  the  anesthetic  type:  Man,  aged  nineteen  years,  a 
Greek,  who  had  been  in  this  country  about  four  years.  The  lesions  were  on  the  flexors 
and  extensors  of  the  thighs,  the  buttock,  the  flexors,  and  extensors  of  the  forearms  and 
elbows.  Diagnosis  was  made  by  incision  into  an  anesthetic  patch  over  the  left  elbow, 
and  this  smear  showed  lepra  bacilli  in  the  blood.  (Dr.  Daniel  Hopkinson  and  Dr.  E.  L. 
Tharinger.) 

Fig.  63. — Same  man  shown  in  Case  I,  Fig.  62. 


In  the  anesthetic  form,  hyperesthesia  and  neuralgia  pains  and 
ulcerations  due  to  trophic  changes  are  notable  features. 

Discolored  spots  appear  upon  the  skin  surface,  and  these  may  be 
followed  by  ulcerations.  Both  forms  may  be  found  together.  Second- 
ary infection  may  lead  to  ulceration  and  gangrene,  with  extensive 
destruction  of  tissue — the  so-called  lepra  mutilans  or  lepra  gangrenosa. 

These  cases  were  rarely  met  with  in  this  country^  and  there  was 
much  confusion  with  regard  to  both  diagnosis  and  treatment.  In 
recent  years  many  cases  have  been  discovered  in  the  Central  States,  as, 


LEPROSY,  LEPRA,  ELEPHANTIASIS  GRECORUM  141 


Fig.  64.— Lepra  bacilli.     Smear  from  incised  nodule.     From  case  illustrated  in  Fig.  62. 


■    If 


Fig.  65. — Lepra  nodule  containinglepra  bacilli.     From  case  illustrated  in  Fig.  66. 


142 


INFECTIOUS  DISEASES 


for  example,  the  two  in  INIihvaiikee,  illustrations  of  which  are  shown  in 
Figs.  62  to  6G.  Nevertheless  the  interest  they  may  have  for  the  oral 
surgeon  is  largely  academic,  and  a  more  extended  description  of  cases 
would  therefore  seem  to  be  unnecessary. 


Fig.  66 


Fig.  67 


Fig.  66. — Case  II.  Nodular  tj^pe  of  leprosy.  Subject  was  a  Greek,  aged  twenty- 
three  j^ears,  in  this  country  about  six  years;  has  had  the  lesions  about  eight  months. 
Nodules  distributed  ov^er  face,  hands,  and  extremities.  He  had  a  rhinitis  for  about  three 
months,  when  the  lesions  first  appeared.  The  nodules  developed  in  considerable  numbers 
and  then  receded.  Diagnosis  was  made  by  excising  a  nodule  in  the  forearm.  The  blood 
smear  showed  typical  lepra  bacilli,  as  illustrated  in  Figs.  64  and  65.  It  is  significant  that 
both  of  these  men  appeared  to  have  contracted  the  disease  in  tliis  country,  unless  the 
inoculation  period  is  really  much  longer  than  is  generally  believed.  (Dr.  Daniel  Hop- 
kinson  and  Dr.  E.  L.  Tharinger.) 

Fig.  67. — Same  patient  as  in  Case  II,  Fig.  66. 


FOCAL  INFECTION  OF  ORAL  ORIGIN. 

For  clinical  purposes  it  seems  best  to  group  for  consideration  in 
this  relation  some  affections  of  the  oral  ca^•ity  that  might  otherwise 
have  been  described  in  other  chapters,  with  their  several  pathological 
classifications. 

Since  Rosenow  brought  to  light  the  theory  of  the  transmutation  of 
microorganisms  in  1913,  the  etiological  and  pathological  importance 
of  the  diseases  of  the  teeth  and  other  oral  structures  has  been  greatly 
emphasized.     All  investigators  do  not  entirely  agree  with  Rosenow's 


FOCAL  INFECTION  OF  ORAL  ORIGIN  143 

findings,  but  the  vast  amount  of  clinical  data  recorded  with  reference 
to  diseases  of  the  mouth  and  dental  organs  that  seem  to  bear  a  vital 
relation  to  general  and  remote  local  affections,  leans  so  strongly  in  this 
direction  that  the  more  or  less  technical  character  of  the  objections  that 
have  been  raised  fall  naturally  to  the  background  of  secondary  considera- 
tion. As  is  usual  under  such  circmnstances  the  pendulum  of  methods 
of  practice  immediately  swung  from  one  extreme  far  over  to  the  opposite 
one,  and  the  sacrifice  of  teeth  at  once  became  the  price  of  insufficient 
general  diagnosis.  When  the  real  cause  of  a  pathological  condition 
situated  in  almost  any  part  of  the  body,  and  of  almost  any  character, 
was  not  very  clear,  in  many  instances  every  tooth  that  was  not  like 
"Caesar's  wife"  was  smnmarily  extracted.  The  natural  result  is  that 
many  people  have  fewer  teeth,  and  often  suffer  great  disadvantage 
from  this  cause,  but  they  still  have  their  original  pathological  affections. 
On  the  other  hand,  there  can  be  no  doubt  of  the  inestimable  importance 
of  diseases  of  the  mouth  and  the  therapeutic  value  of  proper  disposal 
of  these  foci  of  infection. 

According  to  Billings  the  recognition  and  removal  of  the  focus  is 
imperative  as  a  fundamental  principle  to  stop  the  progression  of  ill 
health. 

Rosenow^  gives  the  following  conclusions : 

"The  experiments  on  mutation  show  that  when  these  and  other 
streptococci  are  grown  in  sjTnbiosis  with  other  bacteria,  and  under  a  low 
oxygen  pressure,  they  may  acquire  new  features,  and  that  sometimes 
they  undergo  marked  changes  on  passage  through  animals.  The 
places  in  the  human  body  where  such  conditions  prevail,  and  where 
special  features  are  likely  to  be  acquired,  are  parts  of  infection  such  as 
in  the  tonsils,  various  sinuses,  the  appendix,  and  about  the  gimis  and 
teeth. 

"The  strains  from  muscular  rheumatism,  especially  after  one  oi 
two  animal  passages,  as  well  as  other  streptococci  when  they  have 
attained  a  similar  grade  of  virulence,  show  a  marked  affinity  for  the 
mucous  membrane  of  the  stomach,  the  pelvic  mucous  membrane  and 
medullary  portion  of  the  kidney  and  the  gall-bladder.  Ulcer  of  the 
stomach,  the  picture  of  an  'ascending'  nephritis,  cholecystitis  with 
beginning  formation  of  gall-stones,  caused  by  streptococci,  have  been 
found  repeatedly  in  rabbits  and  dogs  injected  with  strains,  especially 
after  one  or  more  animal  passages. 

"The  essential  element  in  favor  of  the  mutation  of  pathogenic 
microorganisms  in  the  human  body  is  that  the  foci  may  be  suitable 
for  their  long  continuance  of  these  situations. 

"Obviously  then  acute  inflamm-atory  conditions,  the  cardinal 
symptoms  of  which  demand  more  or  less  immediate  relief,  or  abscesses 
in  which  a  sinus  gives  an  exit  to  the  pus,  distressing  or  even  alarming 
as  these  often  appear  to  be,  are  not,  as  a  rule,  the  affections  that  are 
of  most  serious  etiological  importance. 

'  Jour.  Infect.  Dis.,  January,  1914. 


144  INFECTIOUS  DISEASES 

"  Hence  the  comparative  general  limitation  of  acute  diseases  of  the 
periosteal,  osseous,  or  other  tissues  of  the  mouth  as  causative  factors 
to  the  effects  of  acute  infections.  It  is  the  so-called  blind  abscesses, 
the  granulomata,  which  seldom  give  rise  to  noticeable  symptoms  that 
favor  the  continuance  of  bacteria  in  these  foci,  which  gradually  increase 
in  size  as  surrounding  bone  absorption  takes  place,  that  may  so  often 
be  held  accountable  for  remote  chronic  diseased  conditions.  Many 
authorities  now  agree  that  focal  infections  of  this  character  may  have 
an  important  relation  to  cases  of  rheumatoid  arthritis,  iritis,  endo- 
carditis, myocarditis,  ulcer  of  the  stomach,  disease  of  the  kidneys,  or 
anemia,  leukemia,  and  other  affections  manifesting  themselves  through 
blood  disturbances;  chorea  and  many  similar  disorders  of  almost 
unlimited  extent,  or  pathological  manifestations  touching  the  brain, 
spinal  cord  and  nerve  structures  in  which  infection  mav  plav  a  part." 
(See  Fig.  70.) 

Hebble  has  presented,  in  an  article  in  the  Dental  Summary,  some 
facts  and  figures  gleaned  from  the  work  of  important  writers  which  give 
an  adequate  idea  of  the  general  pathological  relation  of  oral  infectious 
foci. 

"According  to  Irons^  an  unselected  group  of  329  patients  in  a  ward 
in  Cook  County  Hospital,  Chicago,  was  studied  and  the  relations 
of  all  discoverable  infectious  processes  tabulated  for  each  patient. 
The  patients  were  then  classified,  according  to  final  diagnosis,  and  the 
percentage  of  each  tjpe  of  infection  in  each  group  calculated.  Roent- 
gen-ray studies,  most  of  which  were  confirmed  by  consultation  with 
dental  surgeons,  were  obtained  of  124  of  the  329  patients.  In  44  per 
cent,  of  the  124  patients  alveolar  abscesses  were  found.  In  the  arthritic 
group  76  per  cent,  had  alveolar  abscesses.  In  the  group  of  nephritis 
and  cardiovascular  disease,  47  per  cent.;  other  diseases,  including 
pneumonias,  23  per  cent.,  or  less  than  one-third  of  the  percentage  in  the 
arthritic  group.  Abnormalities  in  tonsils  as  expressed  by  h^-per- 
trophy  were  present  in  45  per  cent,  of  the  arthritic  groups,  in  24  per 
cent,  of  the  cardiovascular  group,  and  in  19  per  cent,  of  the  remainder. 
Other  chronic  infections,  such  as  those  of  sinuses  or  genito-urinary 
tract,  were  found  in  21  per  cent,  of  the  arthritic  group,  13  per  cent,  in 
the  cardiovascular  group,  and  11  per  cent,  of  the  other  diseases. 
S^TDhilis,  either  from  the  history,  clinical  evidence,  or  "Wassermann, 
was  found  in  23  per  cent,  of  the  arthritic  group,  39  per  cent,  of  the 
cardiovascular  group,  and  13  per  cent,  of  other  diseases. 

"In  experiments  conducted  at  the  University  of  ^Minnesota  Hospital 
by  Ulrich-  a  little  over  61  per  cent,  of  all  artificially  devitalized  teeth 
were  found  with  apical  abscesses,  and  the  total  number  of  abscesses  on 
1350  teeth,  including  those  found  on  non-vital  teeth  due  to  caries  or 
trauma,  was  83  per  cent.  One  hundred  and  fifty-nine  of  these  cases 
had  bacteriological  review.  Henrici  reported  107  cases  from  the  uni- 
versity clinic,  of  which  100  gave  the  Streptococcus  viridans;  52  were 

1  Jour.  Am.  Med.  Assn.,  September  16,  1916. 
*  Ibid.,  November,  1915. 


PLATE   IV 


Dentin  Impregnated   with    Rosin-chloropercha   Solution. 

(Callahan.) 


PLATE   V 


Illustration  of  a  Section  of  a  Tooth  with  the  Dental  Tubuli 
Stained  by  Inieetion  of  the  Tooth  Pulp.  A  Rare  Result  Accom- 
plished by  Dr.  V.  A.   Latham,  of  Chicago. 


Illustration  of  a  Section  of  a  Tooth  with  the  Dentinal  Tubuli 
Stained  by  Injection  of  the  Dental  Pulp.  It  also  Shows  the 
Result  of  a   Pericemental  Abscess.     (Dr.  V.  A.  Lathani.) 


FOCAL  INFECTION  OF  ORAL  ORIGIN 


145 


from  the  private  clinic  of  Ulrich,  50  of  which  gave  Streptococcus 
viridans  or  Streptococcus  hemolyticus.  Occasionally  Streptococcus 
mucosa  was  recovered.  Thus  of  500  cases  examined  150  gave  evidence 
of  streptococcus  either  in  pure  culture  or  as  the  dominant  organism. 
Occasionally  the  Staphylococcus  aureus  or  albus  or  the  Micrococcus 
catarrhalis  was  also  observed  in  conjunction  with  streptococcus. 
Gilmer  and  Moody^  report  streptococci,  both  Streptococcus  viridans 
and  Streptococcus  hemolyticus,  as  well  as  other  organisms,  such  as 
Staphylococcus  aureus.  Micrococcus  catarrhalis,  the  Bacillus  fusi- 
formis,    and    in    two    instances    diphtheroid    bacilli.     Hartzell    and 


Fig.  68. — -Alveolar  abscessed  teeth  showing  granulomatous  and  other  ill  effects  of 
dento-alveolar  abscess  upon  the  roots  of  teeth  and  the  hopelessness  of  endeavoring  to 
save  roots  of  this  character.      (Latham.) 

Henrici-  found  in  162  cases  that  150  yielded  streptococci.  They 
report  inoculation  of  24  rabbits  with  Streptococcus  viridans  isolated 
from  apical  abscesses,  with  the  following  results:  heart  lesions  were 
found  in  5,  kidney  lesions  in  7,  those  of  the  aorta  in  3,  and  of  joints  2. 
"By  actual  weight  and  count  Kligler^  has  shown  that  human  tooth 
scrapings  from  healthy  mouths  contain  from  6,000,000  to  8,000,000 
bacteria  to  the  milligram.  By  weight  and  count  he  has  shown  that 
44  per  cent,  of  this  enormous  mass  of  bacteria  is  streptococci  and 
from  18  per  cent,  to  22  per  cent,  is  staphylococci." 

1  Jour.  Am.  Med.  Assn.,  December  5,  1914. 

2  Ibid.,  March,  1915. 

3  Jour.  Allied  Societies,  September,  1915. 


10 


146  INFECTIOUS  DISEASES 


DENTO-ALVEOLAR  ABSCESSES. 

For  clinical  as  well  as  pathological  reasons  it  is  necessary  to  dis- 
tinguish between  dento-alveolar  apical  abscesses  in  which  there  is 
an  accumulation  of  pus  surrounding  or  associated  with  the  apical  end 
of  the  root  of  a  devitalized  tooth  and  pericemental  abscesses  which 
may  occur  in  connection  with  the  roots  of  teeth  having  vital  pulps. 

Etiology.— A  tooth  pulp  may  become  devitalized  through  its  exposure 
in  the  course  of  dental  caries,  whereby  it  is  subjected  to  irritation  by 
the  secretions  of  the  mouth,  bacterial  invasion  and  other  vicious 
influences.  Severe  traumatic  injury  may  destroy  the  integrity  of  the 
bloodvessels  and  nerves  as  they  enter  the  apical  foramina  and  thus 
cause  loss  of  vitality  in  the  tooth  pulps.  This  may  also  occur  from 
severe  pericemental  inflammation  or  infection  in  this  region.  Septic 
agents  are  then  forced  through  the  apex  of  the  root  by  the  confined 
gases  within  the  pulp  chamber  of  the  tooth,  and  thus  infection  of  the 
alveolar  structures  surrounding  the  apex  of  the  root  results  in  due 
course  in  the  formation  of  a  typical  abscess  at  that  point.  This  may 
extend  until  the  pus  finds  an  exit  through  a  fistulous  opening  in  the 
mouth,  or  failing  this,  becomes  what  is  known  as  a  blind  abscess,  or  the 
pus  may  find  its  way  through  channels  of  bone  until  it  reaches  some 
more  distant  point  of  exit,  such  as  the  maxillary  sinus  or  the  nasal 
cavity.  The  so-called  blind  abscess,  the  granuloma,  with  its  protective 
wall  in  the  form  of  an  enclosing  fibrous  sac,  containing  lymphocytes 
and  leukocytes,  is  apparently  partly  due  to  proliferation  of  the  peri- 
cementum in  response  to  chronic  inflammation  and  also  to  the  usual 
lymph  protection  thrown  out  in  the  course  of  abscess  formation. 

Diagnosis. — In  discovering  the  existence  of  these  foci  no  other  agent 
is  so  useful  as  the  .r-rays.  Radiographs  such  as  in  Figs.  69  and  70 
usually  show  quite  distinctly  the  dark  areas  surrounding  the  affected 
portion  of  the  root.  The  essential  feature  in  testing  the  teeth  is  to 
determine  if  the  pulp  be  vital.  This  may  be  accomplished  by  the  aid 
of  the  interrupted  current,  or  the  application  of  heat  or  cold  to  deter- 
mine the  sensitiveness  to  thermal  changes,  will  often  lead  in  the  direc- 
tion of  the  discovery  of  these  foci. 

Treatment. — The  author  does  not  hold  with  Rosenow  that  every 
devitalized  tooth  root  is  necessarily  a  menace  because  the  tubuli  of  the 
dentin  may  harbor  microorganisms  even  though  the  root  canal  be 
completely  filled.  He  does  believe  that  once  septic  conditions  have 
taken  place  within  the  pulp  chamber  of  the  tooth  that  it  is  not  only 
necessary  to  have  the  root  canal  properly  filled  to  the  apex  with  gutta- 
percha or  some  equally  suitable  root-filling  material,  but  that  it  is 
also  in  the  highest  degree  necessary  that  the  dentinal  tubuli  should  be 
sealed  according  to  the  Callahan  or  some  equally  effective  method. 
Figs.  71  and  72  illustrate  the  importance  of  this  statement.  It  can 
only  be  determined  that  this  has  been  successfully  accomplished  by 


DENTO-ALVEOLAR  ABSCESSES 


147 


taking  other  radiograms  to  show  the  actual  condition  of  the  root  after 
it  has  been  filled. 

Exsection  of  the  Roots  of  Teeth.-^The  amj)iitation  of  the  apical  end 
of  the  root  of  a  tooth,  the  so-called  apiectomy,  is  very  generally  prac- 
tised among  dentists.     In  some  cases  this  treatment  is  warranted  and 


Fig.  69  Fig.  70 

Fig.  69. — Dento-alveolar  abscess  associated  with  pernicious  anemia. 
Fig.  70. — Defective  root  fillings  from  the  moutli  of  a  business  man  with  extensive 
interests,  who  broke  down  so  completely  that  he  was  obliged  to  give  up  work  and  with- 
draw from  active  participation  in  the  direction  of  the  institutions  with  which  he  was 
connected.  Travel  abroad,  trips  to  Carlsbad  and  other  watering  places,  with  consulta- 
tion by  prominent  internists  in  this  country  and  Europe  gave  no  relief  and  no  definite 
diagnosis.  Urinalyses  and  blood  examinations  gave  every  e\'ideDce  of  diseased  condi- 
tions, but  no  light  as  to  the  cause.  Complete  recovery  followed  the  treatment  and  extrac- 
tion of  several  diseased  teeth. 

many  useful  dental  organs  have  thus  been  preserved  without  preju- 
dice to  general  health;  on  the  other  hand,  the  indiscriminate  appli- 
cation of  this  method  may  occasionally  result  in  the  retention  of  a  focus 
of  infection  of  somewhat  more  serious  character  than  before  treatment. 
Verv  careful  discrimination  is  necessarv  to  determine  in  serious  cases 


Fig.  71  Fig.    ,  2 

Fig.    71. — Large   dento-alveolar   abscess   associated   with     a   devitalized    gangrenous 

pulp  in  the  lateral  incisor,  the  root  of  which  was  not  filled,  and  imperfectly  filled    root 

canals  in  the  first  bicuspid  and  central  incisor  teeth.      In  this  case  the  maxillary  sinus 

was  also  involved. 

Fig.  72. — Dento-alveolar  abscess  and  bone   destruction  due  to  pyorrhea    alveolaris. 

The  maxillary  sinus  was  involved  in  this  case.  • 


whether  the  root  should  be  extracted  or  retained  through  the  assistance 
of  this  t^pe  of  operative  treatment.  No  matter  what  individual 
opinion  might  dictate  it  is  only  safe  to  prove  the  result  by  a  radio- 
graphic picture  after  sufficient  time  has  elapsed  to  permit  the  oblitera- 
tion of  the  cavity  in  the  bone  by  new  tissue  formation.     If  this  is  found 


148 


INFECTIOUS  DISEASES 


to  be  the  case  one  year  or  longer  after  the  operation,  and  the  original 
symptoms  of  focal  infection  seem  to  have  permanently  disappeared, 
then  the  retention  of  the  root  is  warranted,  otherwise  the  grave  patho- 
logical possibilities  for  which  such  a  condition  may  be  responsible  are 
too  great  to  weigh  in  the  balance  against  the  retention  or  loss  of  one 
or  even  all  the  teeth.  What  is  true  of  dento-alveolar  abscesses  as  a 
menace  to  general  health,  is  also  true  in  regard  to  roots  of  teeth  affected 
by  pyorrhea  alveolaris.  In  these  cases  it  is  sometimes  difficult  to 
determine  whether  the  pyorrhea  is  the  result  of  some  kidney  or  other 
affection  or  if  the  nephritic  disease  be  the  direct  result  of  the  effect  of 
the  oral  condition.  It  is  safe,  however,  to  say  that  under  all  circum- 
stances every  effort  should  be  made  to  completely  eradicate  the  mouth 
disease.  If  this  can  be  done  safely  by  keeping  the  progress  of  the 
pyorrhea  sufficiently  in  check  to  prevent  continuance  of  infection 
from  that  region  then  such  teeth  mav  be  safely  retained;  if  not,  then 


Fig.  73  Fig.  74 

Fig.  73. — Radiogram  showing  the  result  of  a  dento-alveolar  abscess.  In  this  case 
there  was  an  acute  arthritic  affection  of  the  left  shoulder,  severe  long-continued  headache 
and  progressive  loss  of  vision.  All  these  symptoms  were  relieved  after  surgical  treatment 
of  the  diseased  area,  and  proper  filling  of  the  root  canals  of  the  affected  teeth. 

Fig.  74. — Radiogram  taken  approximately  one  year  after  the  one  shown  in  Fig.  73 
for  the  same  patient.    Bone  regeneration  in  the  diseased  area  is  evident. 

the  removal  of  the  dental  organs  is  the  only  safe  procedure.  It  must 
be  remembered  that  once  the  pericementum  is  destroyed  from  a  root 
surface  it  has  never  been  successfully  proved  that  this  membrane  would 
regenerate  sufficiently  to  again  cover  that  surface  perfectly,  whether  it 
be  an  area  of  denuded  root  surface  at  the  apical  portion  from  a  dento- 
alveolar  abscess  or  upon  some  aspect  of  the  side  of  the  root  from  pyor- 
rhea alveolaris.  In  either  case  there  will  be  predisposition  to  the  con- 
tinuance of  the  focus  of  infection  unless  this  can  be  surgically 
obliterated. 

The  occasional  necessity  of  recognizing  an  association  of  chronic 
affections  and  giving  relief  through  complete  obliteration  of  other 
factors  as  well  as  those  concerning  the  teeth  is  illustrated  in  Fig.  73. 

The  author  has  given  the  following  rules  for  the  guidance  of  physi- 
cians and  surgeons  and  dentists  in  his  article  in  Ochsner's  Surgery: 

"I.  It  must  be  admitted  that  the  value  of  a  tooth  or  teeth  cannot 


DEN  TO-ALVEOLAR  ABSCESSES 


149 


be  allowed  to  weigh  in  the  balance  against  the  reasonable  possibility  of 
serious  general  affections.  Extraction  should  therefore  be  insisted 
upon  unless  complete  security  in  this  respect  can  be  given  by  the  treat- 
ment of  the  roots  of  such  teeth. 

"2.  If  an  attempt  be  made  to  treat  the  root  canals  of  suspicious 
teeth  under  these  circumstances  the^ sealing  of  the  tubuli  according 
to  the  Callahan  or  some  similar  method  should  be  insisted  upon. 


Fig.  75. — Illustration  of  the  case  of  a  young  girl  who  had  for  some  time  been  bed- 
ridden with  arthritis.  Vaccines  and  other  methods  of  treatment  had  been  tried  without 
avail.  Her  mouth  and  teeth  were  put  in  order  at  the  cUnic  of  the  Southern  Dental  College 
and  maxillary  separation  to  widen  her  nose  and  give  better  drainage  to  the  nasal  accessory 
sinuses  was  performed  under  the  direction  of  Dr.  S.  W.  Foster,  of  Atlanta.  The  result 
was  complete  recovery.  At  the  last  report,  a  j'ear  or  more  after  treatment,  she  was  able 
to  wear  a  No.  3  instead  of  a  No.  5  shoe,  and  was  able  to  run  up  stairs  as  well  as  anybody. 

"3.  There  should  not  be  only  radiograms  to  show  the  condition 
before  treatment,  but  immediately  after  also  to  prove  that  the  root 
filling  has  reached  the  apical  end  of  the  root.  If  the  root-canal  filling 
is  imperfect  it  should  be  made  perfect  or  the  tooth  extracted. 

"4.  After  a  sufficient  interval  has  elapsed  another  radiogram  should 
be  taken  if  necessary  to  demonstrate  beyond  the  question  of  a  doubt 
that  there  has  been  complete  regeneration  of  the  bone  and  pericemental 


150 


INFECTIOUS  DISEASES 


structures  surrounding  the  end  of  the  root,  with  total  obHteration  of 
the  abscess.  With  such  care  many  teeth  could  undoubtedly  be  saved 
with  safety.  Without  such  precaution  the  only  safe  procedure  is  to 
extract  the  teeth  in  order  to  remove  the  risk  of  continuation  of  the 
disease. 

"5.  It  must  not  be  forgotten  that  in  many  instances  the  indiscrimi- 
nate extraction  of  teeth  to  relieve  remote  affections  in  the  absence 
of  complete  diagnosis  for  the  exclusion  of  other  causes  is  a  doubtful 
endeavor  to  relieve  present  ills  with  almost  certain  invitation  of  future 


Fig.  76. — This  girl  is  the  subject  of  the  illustration  of  arthritis  in  Fig.  75. 
appearance  of  the  nose  is  important. 


The  narrow 


disturbance.  The  extraction  of  even  one  tooth  from  a  perfect  dental 
arch  paves  the  way  for  malocclusion  which  may  lead  to  pyorrhea 
alveolaris  or  some  similar  affection  in  the  future.  The  loss  of  a  number 
of  teeth  destroys  the  functional  activity  of  the  jaws  and  may  make 
itself  felt  in  the  disarrangement  of  the  digestive  tract  at  some  later 
period.  Moreover,  the  effect  upon  metabolism  of  proper  or  improper 
mastication  of  food  is  one  that  cannot  lightly  be  overlooked." 

With  the  foregoing  rules  for  guidance  much  may  be  done  with  safety 
for  the  simultaneous  relief  of  focal  infections  and  tooth  preservation. 


CHAPTER  IV. 

DISEASES  OF  THE  IMUCOUS  ME!\IBRANE  OF  THE 

MOUTH. 

STOMATITIS. 

IxFLAMMATiox  of  the  miicous  membrane  of  the  mouth.  This  term 
is  used  to  inchide  all  inflammatory  conditions  affecting  the  mucous 
surfaces  of  the  giims,  cheeks,  lips,  and  tongue. 

Marginal  Gingivitis. — Marginal  gingivitis  is  for  clinical  purposes 
assimied  to  be  a  slight  inflanmiatory  condition  apparently  confined 
to  the  border  of  the  gmus  at  the  necks  of  the  teeth. 

Etiology. — It  may  be  evidence  of  some  general  condition  of  disturbed 
digestive  or  other  function;  most  frequently  it  is  caused  by  uncleanli- 
ness,  favoring  the  collection  of  food  particles,  bacteria,  and  salivary 
calculus  in  this  region. 

Symptoms. — The  gum  margins  are  red  and  inflamed,  and  may  also 
become  more  or  less  everted. 

Treatment. — The  treatment  consists  in  the  restoration  of  healthful 
conditions  by  cleaning  and  scaling  the  teeth,  the  remo\'al  of  any  local 
irritant  that  may  be  a  factor,  and  the  application  of  tincture  of  iodin 
to  the  inflamed  gum  borders. 

Interstitial  Gingivitis. — The  term  interstitial  gingivitis  includes  not 
only  the  gum  borders,  but  the  interstitial  tissues  as  well,  and  involves 
all  the  alveolar  structures,  including  the  pericementum,  connective 
tissue,  gums,  and  bone.  Talbot,  who  introduced  this  term,  designed  it 
to  include  all  of  a  considerable  variety  of  terms  which  technically 
represent  dift'erent  stages  of  the  same  disease,  although  by  adoption 
they  are  accepted  in  a  more  general  sense.  Examples  of  these  are: 
Calcic  pericementitis,  phagedenic  pericementitis,  pyorrhea  alveolaris, 
Rigg's  disease,  chronic  alveolitis,  etc. 

Etiology .^ — Its  causes  are  predisposing  and  exciting,  local  and  general, 
or  constitutional. 

Talbot  holds  that  on  account  of  the  transitory  nature  of  the  alveolar 
structures  there  is  a  natural  predisposition  to  their  early  absorption. 
For  this  reason  and  because  of  the  peculiar  nature  of  the  circulatory 
conditions  in  this  region  they  are  unusually  susceptible  to  all  constitu- 
tional toxic  influences.  Therefore  the  eft'ect  of  the  administration  of 
mercury,  lead,  iodin,  and  other  poisons  of  similar  nature  gives  earh' 
manifestation  at  the  gum  margins,  and  in  like  manner  these  structures 
are  influenced  by  auto-intoxication  from  gastro-intestinal  leukomains 
and  toxemias;  from  acute  infectious  diseases  as  well  as  faulty  metab- 

(151) 


152  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

olism  due  to  chronic  nutritional  disturbances;  organic  affections 
leading  to  diseased  conditions  of  the  blood,  and  disorders  of  the  central 
nerve  system.  Indican,  the  product  of  indol,  resulting  from  intestinal 
fermentation,  Talbot  has  shown  to  be  almost  constantly  in  excess  in 
the  urine  of  patients  suffering  from  this  aft'ection,  as  is  also  acidosis 
evidenced  by  excess  acidity  above  40  per  cent.,  or  acidity  below  30 
per  cent.,  an  indication  of  insufficiency  of  renal  elimination. 

Symptoms. — Cases  of  interstitial  gingivitis,  in  which  the  symptoms 
are  chiefly  confined  to  the  roots  of  the  teeth  and  the  structures  immedi- 
ately surrounding  them,  are  successfully  treated  by  dentists,  although 
they  usually  require  constitutional  treatment,  that  should  be  directed 
toward  the  cure  of  the  underlying  causes,  and  do  not  demand  considera- 
tion from  a  surgical  point  of  view.  When,  however,  such  conditions 
menace  and  involve  adjacent  bone  and  soft  tissues  extensively,  they  may 
lead  to  serious  pathological  nervous  conditions  of  quite  general  nature 
by  reason  of  the  continued  irritation  of  the  loosened  teeth.  Disturb- 
ance of  the  digestive  tract  may  be  brought  about  through  insufficient 
mastication  and  insalivation,  or  through  swallowing  pyogenic  micro- 
organisms which  sometimes  seriously  affect  the  stomach  and  intestine. 
Extensive  necrosis  of  the  jaAVs  or  infectious  conditions  may  penetrate 
the  cavities  of  the  nose  or  maxillary  antra,  affect  the  glands  of  the 
lymphatic  system  and  the  salivary  glands,  or  lead  to  gangrenous 
affections  of  the  mouth.     These  conditions  require  surgical  attention. 

Treatment. —  General  treatment  of  these  cases  should  be  corrective 
by  administration  of  cathartics,  regulation  of  the  quantity  of  water 
to  be  taken  during  each  twenty-four  hours,  administration  of  diuretics 
if  required;  the  adoption  of  suitable  dietetic  rules  by  the  increase  of 
vegetable  food  if  there  be  tendency  to  scur\y,  limiting  the  amount  of 
red  meat,  and  additions  to  control  the  carbohydrates.  Careful  atten- 
tion should  be  given  to  secure  nourishment  that  will  be  strengthening 
and  at  the  same  time  easily  assimilated,  and  effort  should  be  made 
to  overcome  directly  the  condition  of  acidosis. 

The  loose  teeth,  if  the  possibility  of  their  retention  be  hopeless, 
should  be  removed;  those  that  can  be  retained  should  be  fastened  by 
retaining  appliances,  or  bridge--\\ork  which  will  attach  them  to  other 
teeth  in  the  mouth.  IMalocclusion  is  invariably  present  whether  the 
teeth  are  regular  in  form  and  position  or  not.  The  occlusal  surfaces 
must  for  this  reason  be  ground,  and  the  teeth  protected  by  appliances 
against  movement  in  all  directions.  The  distributions  of  the  stress  so 
that  in  closure  of  the  jaws  it  will  be  divided  among  a  number  of  teeth 
instead  of  being  applied  to  each  single  one,  gives  a  steadiness  that  not 
only  relieves  the  local  irritation,  and  helps  constructive  cell  efforts  to 
restore  and  enable  the  tissues  immediately  surrounding  the  roots  to 
become  tightened  and  more  healthful,  but  causes  at  the  same  time  an 
abatement  of  nervous  sjTnptoms  which  is  quite  generally  beneficial. 

One  of  the  most  common  causes  of  failure  to  respond  to  treatment 
in  these  cases,  and  at  the  same  time  a  most  active  factor  in  extending 


STOMATITIS  153 

destructive  pathological  processes,  is  the  fact  that  extension  of  the 
inflammatory  condition  along  the  pericementum  finally  reaches  the 
apical  end  of  the  root  and  attacks  the  nerve  and  l)loodvessels  as  they 
pass  through  the  apical  foramen  to  join  the  general  supply,  thus  causing 
strangulation  at  this  point,  which  leads  to  devitalization  and  ultimately 
through  infection  to  gangrenous  conditions  of  the  tooth  })ulp.  On 
accoimt  of  the  fact  that  there  is  frequently  no  cavity  or  external  imper- 
fection noticeable  in  the  crown  of  the  tooth,  this  condition  may  not  be 
properly  diagnosticated  and  the  pulp  chambers  of  such  teeth  then 
become  veritable  wells  of  pus,  discharging  a  more  or  less  continuous 
supply  of  infection  to  continue  abscesses  and  necrotic  conditions 
almost  indefinitely.  Opening  through  the  tooth  crown,  cleansing  and 
disinfection  of  the  roots  are  simple  measures  to  be  adopted  in  treat- 
ment, but  without  this  care  other  treatment  is  absolutely  useless. 
Necrosis  and  other  pathological  results,  as  evidenced  in  the  oral  cavity, 
or  extension  of  disease  to  other  regions,  require  treatment  appropriate 
to  the  pathological  state,  whatever  it  may  be. 

For  local  application  the  tincture  of  iodin,  or  Talbot's  iodoglycerol, 
may  be  used  with  benefit: 

Zinc  iodide 15  parts 

Distilled  water 10     " 

Iodin 25     " 

Glycerin 50     " 

Since  the  first  edition  of  this  work  was  written  the  excitement 
occasioned  by  the  theory  of  the  Endameba  buccalis  as  an  etiological 
factor  per  se,  and  the  use  of  emetin  as  a  positive  curative  agent  has  come 
and  gone,  leaving  behind  it  a  measure  of  truth  and  some  interesting 
facts  that  when  properly  applied  may  have  therapeutic  value.  Since 
the  publication  in  the  August,  1914,  number  of  the  Dental  Cosmos 
of  the  article  by  Dr.  Allen  J.  Smith,  professor  of  pathology  in  the  school 
of  medicine  of  the  University  of  Pennsylvania,  and  M.  T.  Barrett, 
D.D.S.,  instructor  of  normal  histology  in  the  same  institution,  relating 
to  the  presence  of  parasitic  amebse  in  pyorrhea  alveolaris  and  their 
belief  in  the  use  of  emetin  for  its  treatment,  much  has  been  written  by 
Bass  and  Johns  and  other  writers,  the  effect  of  which,  coming  as  it  did 
from  men  in  high  authority,  has  been  almost  vicious  in  its  influence  upon 
the  methods  of  treatment  of  this  disease.  The  theory  of  the  efficacy  of 
emetin  is  largely  based  upon  the  findings  of  Col.  Leonard  Rogers,  of  the 
Indian  Medical  Service  in  Calcutta,  who  in  1912  demonstrated  this 
to  be  a  useful  as  well  as  specific  remedy  against  endameba.  In  justice 
to  Drs.  Smith  and  Barrett,  who  have  been  so  widely  misquoted,  the 
following  extract  from  a  personal  letter  from  Dr.  J.  Allen  Smith  to  the 
author,  which  is  quoted  from  the  author's  article  in  Ochsner's  Surgery, 
should  be  considered. 

"  There  are  two  forms  of  these  parasites  which  may  be  found  in  and 
about  the  mouth,  viz.,  Endameba  gingivalis  (Gross  in  1849  appears  to 


154  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

have  been  the  first  to  pubhsh  and  discover  the  amebic  parasites  in  the 
soft  material  on  and  about  the  teeth)  and  Endameba  pyogenes.^  Ap- 
parently either  of  these  two  ameba?  may  be  met  in  pyorrhea  pus, 
but  the  first  is  the  only  one  Dr.  Barrett  and  I  have  found  therein. 
We  do  not  believe  that  these  are  alone  responsible  for  pyorrhea  suppu- 
rations, and  do  believe  pyorrhea  may  occur  without  their  i)resence,  but 
we  do  believe  they  are  present  in  the  great  majority  of  such  lesions, 
which  we  speak  of  therefore  as  amebic  pyorrhea.  We  think  their 
importance  comes  especially  from  a  symbiosis  with  the  vegetable 
microorganisms  therein  found,  and  we  beheve  we  break  one  link  of  that 
symbiotic  chain  when  we  use  emetin,  which  is  an  efficient  amebicide, 
but. (so  far  as  known)  only  a  poor  bactericide.  The  chain  broken  in  this 
wise  the  suppuration  stops.  But  the  same  result  might  be  obtained  by 
cleaning  out  both  the  amebse  and  the  bacteria  by  proper  mechanical  and 
antiseptic  work,  or  it  might  be  obtained  by  efficient  bactericides  as  the 
exactly  suitable  vaccine  for  the  individual  case.  To  attack  the  amebic 
end  of  this  symbiotic  chain  by  emetin  is  the  easy  method,  and  seems 
to  be  providing  commonly  the  most  efficient  method;  but  we  would 
be  improperly  quoted  if  we  were  held  to  regard  it  as  the  only  method." 

The  frequent  presence  of  endameba  in  the  discharges  from  pj'orrheal 
pockets  is  generally  admitted.  Their  importance  as  primary  etiological 
factors  has,  however,  been  very  generally  disproved.  There  seems  to 
be  no  good  objection  to  the  introduction  into  the  pyorrhea  pockets,  with 
an  ordinary  hypodermic  syringe  properly  used,  of  any  of  the  various 
preparations  of  emetm  hydrochloride  solution  in  addition  to  other 
methods  of  treatment  that  have  been  given.  There  are,  however, 
many  good  and  sufficient  reasons  why  the  general  use  of  the  hypo- 
dermic administration  of  half-grain  doses  of  emetin  hydrochloride 
hypodermically  each  day  for  three  to  six  days,  as  recommended  by 
Bass  and  Johns,  should  be  avoided,  except  when  there  is  some  unusual 
general  indication  for  such  treatment. 

Stomatitis  Simplex. — A  slight  more  or  less  transient  eruption  affecting 
the  buccal  mucous  membrane.  Eruptions  of  this  character  are  usually 
coincident  with  similar  aft'ections  upon  the  skin  surfaces.  These,  as 
is  well  known,  are  the  outward  expressions  of  digestive  disturbances, 
contagious  infections,  and  specific  diseases,  and  the  simplest  of  all 
forms  of  stomatitis,  which  chiefly  affects  young  infants  is  also  due  to 
gastro-intestinal  disarrangement. 

Symptoms. — The  symptoms  are  red  elevated  patches  on  the  mucous 
membrane  of  the  mouth.  They  are  of  bright  color,  appear  suddenly, 
and  usually  disappear  in  the  course  of  a  few  hoiu"s  or  a  few  days. 
Infants  so  affected  usually  show  other  symptoms  indicative  of  dis- 
turbed nervous  and  digestive  function,  such  as  unusual  flow  of  saliva, 
occasional  rise  of  temperature,  restlessness,  undigested  matter,  or 
greenish  color  of  stools,  etc. 

1  Verdam  and  Bryant:  L'^cho  Med.  du  Nord.,  1907,  xl,  375. 


STOMATITIS  155 

Treatment. — Treatment  consists  of  correction  of  unhygienic  con- 
ditions. If  the  cliild  be  bottle-fed,  there  should  be  careful  sterilization 
of  the  bottle,  nipi)le,  etc.,  and  readjustment  of  the  formula  of  its  food 
to  conform  to  the  digestive  requirements.  Plenty  of  fresh  air,  cleans- 
ing of  the  digesti^•c  tract  by  administration  of  castor  oil,  and  high  bowel 
flushing  if  necessary  are  also  indicated.  The  mouth  should  be  cleansed 
with  boric  or  other  mildly  antiseptic  solutions. 

Stomatitis  Catarrhalis  {Catarrh  of  the  Oral  Mucous  Membrane). — 
Etiology. — Stomatitis  catarrhalis  occurs  more  commonly  in  children 
than  adults.  Neglected  cases  of  simple  stomatitis,  direct  irritation  by 
heat,  liquid  or  chemical  substances,  uncleanly  conditions  of  the  mouth, 
chronic  disorders  of  the  general  system,  mouth-breathing,  and  catarrh 
of  the  nasal  mucous  membrane  may  predispose  or  act  as  direct  etio- 
logical factors. 

Symptoms. — The  mucous  membrane  of  the  mouth  is  red  and  fre- 
quently covered  with  considerable  liquid  exudate;  small  vesicular 
cysts  may  form  from  distention  of  the  mucous  glands,  and  sometimes 
grayish  erosions  appear. 

Treatment. — Treatment  requires  correction  of  the  general  causes 
by  hygienic  care,  which  embraces  cleansing  of  the  mouth  and  body, 
both  externally  and  internally,  and  the  administration  of  cathartics, 
attention  to  digestive  conditions,  fresh  air,  use  of  mild  antiseptic  mouth 
washes.  Infants  or  young  children  suffering  from  either  simple  or 
catarrhal  form  of  stomatitis  should  be  given  careful  attention  with 
regard  to  erupting  teeth,  and  to  gums  freely  lanced,  if  necessary.  Any 
disadvantageous  conditions  that  may  unpede  the  progress  of  teeth  in 
course  of  eruption  must  also  be  overcome  and  carious  or  otherwise 
diseased  teeth  properly  disinfected  and  treated. 

Aphthous  Stomatitis. — Aphthous  stomatitis  occurs  in  both  children 
and  adults,  but  more  frequently  in  the  former. 

Etiology. — It  is  the  result  of  malhygiene  or  of  gastro-intestinal  or 
other  disease.  Quite  frequently  when  found  in  adult  cases  it  is  merely 
an  indication  of  some  passing  digestive  disturbance  of  temporary 
nature. 

Symptoms.- — The  little  aphthae  or  cankers  form  usually  in  the  folds 
at  the  jimction  of  the  mucous  membrane  of  gimi  and  lips,  or  cheeks. 
Little  oval,  bright  red  spots  are  usually  first  noticed  because  of  the  fact 
that  they  are  highly  sensitive  to  touch  and  to  sweet  and  sour  substances 
taken  into  the  mouth.  These  points  of  irritation  quickly  assmue  a 
grayish-white  appearance,  because  of  the  degeneration  of  epithelium 
that  takes  place  upon  the  surfaces.  A  number  of  these  may  occiu-  in 
the  same  locality  and  by  confluence  become  joined  into  a  single  large 
one,  but  the  inflamed  outline  of  the  border  retains  either  the  original 
oval  form  or  its  shape  indicates  the  joining  together  of  one  or  more 
individual  oval  patches.  The  lesions  are  superficial  and  do  not  have 
a  tendency  to  penetrate  deeply  and  to  affect  the  underlying  bone 
structures  (Plate  VI,  Fig.  1). 


156  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

Treatment. — The  local  treatment  consists  of  touching  the  cankers 
with  caustic  nitrate  of  silver  or  95  per  cent,  carbolic  acid,  followed  by 
alcohol  or  nitric  acid  to  cauterize  the  surfaces.  Thorough  cleansing 
of  the  mouth,  the  use  of  suitable  mouth  washes,  and,  if  necessary, 
correction  of  the  predisposing  gastro-intestinal  condition. 

Bednar's  Aphthae. — These  are  small  ulcers  found  in  the  mouths  of 
sucking  infants,  situated  at  the  lateral  portions  of  the  palate  and  in 
other  places  where  the  surfaces  would  be  likely  to  be  affected  by 
traumatism  during  the  act  of  sucking,  which  is  their  probable  cause. 

Treatment. — The  only  remedies  suggested  in  these  cases,  if  the  child 
be  bottle-fed,  are  the  administration  of  nourishment  by  spoon  or  with 
a  medicine  dropper,  and  if  possible  the  correction  of  any  irritating  habit 
that  may  have  been  acquired,  such  as  thumb  sucking  or  sucking  at  an 
empty  nipple,  as  is  sometimes  allowed. 

Ulcerative  Stomatitis. — Ulcerative  stomatitis  is  the  most  difficult 
of  all  forms  of  stomatitis  to  differentiate  from  other  types  of  this 
affection,  because  the  inflamed  areas  between  and  around  the  necks 
of  the  teeth  affecting  the  gums  and  other  surfaces  of  the  buccal  cavity 
may  be  associated  with  symptoms  of  many  varieties  of  inflammation 
of  these  structures. 

Etiology. — It  may  be  the  direct  result  of  interstitial  gingivitis  or 
may  be  due  to  causative  factors  such  as  general  infection,  mineral 
poisons,  disorders  of  the  general  system,  local  irritation,  etc.,  which 
are  usually  accompanied  by  quite  similar  ulcerative  and  destructive 
processes.  For  clinical  purposes  it  is  necessary  to  make  a  more  or  less 
arbitrary  distinction  by  which  we  recognize  this  condition  as  a  disease 
affecting  both  children  and  adults,  the  former  chiefly  under  conditions 
of  malhygiene,  insufficient  nom-ishment,  and  depletion  of  the  system  by 
long-continued  fevers  or  the  effect  of  the  various  eruptive  diseases 
common  to  early  life  and  older  persons  from  general  uncleanliness, 
dissipation,  excessive  smoking  or  drinking,  and  similarly  induced 
factors. 

Symptoms.- — This  form  of  stomatitis  is  noted  for  its  grayish-white 
slough  of  irregular  outline;  it  usually  begins  at  or  close  to  the  gum 
margins  and  extends  until  it  includes  adjacent  tissues.  It  is  distin- 
guished from  aphthous  ulcers  by  its  irregular  outline  and  the  tendency 
to  begin  upon  the  gum  rather  than  the  cheek  or  lip  surfaces,  and  by  the 
fact  that  it  attacks  the  bone  and  deeper  structures;  from  pyorrhea 
alveolaris  because  instead  of  clearly  defined  pockets  with  pus  secretion 
it  spreads  out  upon  the  surface  and  the  process  is  an  ulcerative  one; 
from  mercurial,  syphilitic,  and  other  diseases  of  the  mucous  membrane 
of  the  mouth  by  recognition  of  their  special  etiological  factors.  It 
frequently  leads  to  extensive  necrosis  of  the  maxillary  bones  in  children, 
particularly  between  the  ages  of  five  and  twelve  years.  This  is  doubt- 
less due  to  the  fact  that  the  jaws  are,  at  this  particular  time,  so  filled 
with  developing  teeth  that  the  actual  bone  resistance  and  blood  circu- 
lation are  reduced,  and  also  because  at  this  period  the  diseases  incident 


PLATE    VI 


Aphthous  Stomatitis 

FIG.   2 


Gangrenous  Stomatitis. 

FIG.  3 


Noma. 


STOMATITIS  157 

to  childhood,  both  local  and  general,  predispose  to  affections  of  this 
character. 

Prognosis. — If  the  underlying  cause  has  been  properly  reached,  the  re- 
covery and  improvement  should  be  prompt.  When  it  occurs  slowly,  one 
should  be  on  guard  against  some  factor  that  may  have  been  overlooked. 

Treatment. — Clean  the  teeth,  remove  the  tarter  and  other  irritating 
substances  from  between  and  about  their  necks.  Remove  or  disinfect 
diseased  roots  of  teeth,  curette  sloughing  gum  margins,  and  smooth 
with  a  bone  curette  or  dental  engine  bur  the  roughened  borders  of  the 
alveolar  process.  Paint  the  gum  border  and  entire  diseased  surfaces 
with  tincture  of  iodin;  correct  the  etiological  factors  whatever  they 
may  be.  (For  treatment  of  necrosis  of  the  jaw  resulting  from  this 
disease,  see  Necrosis,  page  326.)  Direct  improvement  of  dietetic  and 
hygienic  conditions.  In  young  children  attention  should  be  given  to 
developing  unerupted  teeth  which  may  become  involved  and  through 
their  devitalization  act  as  complicating  factors  aiding  in  continuing 
infection.  Appropriate  treatment  is  demanded  in  all  cases  showing 
enlarged  tonsils,  adenoid  vegetations  in  the  nasopharynx,  irregular  and 
contracted  dental  arches,  and  deflected  nasal  septa,  all  of  which  are 
usually  associated  in  anemic,  ill-developed  children.  Nervous  and 
other  habits  that  may  be  indications  of  continued  irritation  in  other 
parts  should  also  receive  due  .attention.  In  the  author's  experience 
adult  patients  suffering  from  this  affection  have  usually  been  those 
who  smoked  excessively,  particularly  cigarettes,  who  drank  liquor 
freely,  or  depleted  their  systems  through  other  habits  of  dissipation,  or 
who  had  disease  of  the  kidneys,  liver,  and  other  organs,  and  particu- 
larly diseases  of  the  blood,  such  as  acute  leukemia  and  pernicious  anemia, 
of  which  it  is  usually  one  of  the  earliest  symptoms.  Local  causes  in 
many  of  his  cases  were  irritations  and  infection  from  neglect  of  brush- 
ing the  teeth  or  cleansing  the  mouth.  More  often,  however,  the 
insertion  of  bridges  between  teeth  without  due  care  for  self-cleansing, 
and  with  disregard  of  occlusal  conditions,  not  only  favored  the  collec- 
tion of  debris  under  and  around  them,  but  in  closure  of  the  jaws  the 
unusual  stress  of  malocclusion  kept  up  a  chronic  irritation  and  reduced 
the  resistance  of  the  tissues  to  bacteria.  All  irritating  dental  condi- 
tions, crowns,  bridges,  plates,  or  whatever  they  may  be,  should  be 
removed  at  once.  Immediate  reform  with  regard  to  smoking  and  other 
habits  must  be  insisted  upon.  Urine  for  twenty-four  hours  saved  and 
carefully  analyzed  and  its  indication  followed  in  treatment.  In 
serious  or  persistent  cases  a  careful  blood  examination  should  be  made. 
By  reference  to  the  case  described  under  the  heading  Leukemic 
Stomatitis,  p.  164,  the  importance  of  these  examinationns  will  be 
better  understood. 

Gangrenous  Stomatitis  (Plate  VI,  Fig.  2),  Cancrum  Oris,  Noma 
(Plate  VI,  Fig.  3). — Gangrenous  stomatitis  usually  attacks  the  gums 
or  cheeks,  the  slough  extending  until  it  involves  a  considerable  portion 
of  the  face. 


158  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

Etiology. — This  disease  is  undoubtedly  of  infectious  origin.  While 
attempts  have  been  made  to  identify  a  specific  germ,  the  results  in 
this  direction  have  not  been  such  as  to  warrant  general  acceptance. 
The  bacillus  described  by  Lingard  has  been  found  in  a  small  percentage 
of  cases,  but  streptococci,  staphylococci,  leptothrix,  and  other  micro- 
organisms have  been  identified  in  these  cases  so  frequently  that  there 
seems  to  be  no  doubt  that  the  affection  is  polymicrobic.  It  frequently 
follows  measles,  whooping-cough,  scarlet  fever,  and  other  infections. 
In  these  cases  there  seems  to  be  some  underlying  systemic  condition 
which  predisposes  to  gangrene  rather  than  to  other  manifestations  of 
mouth  infection.  Although  most  commonly  affecting  ill-fed  and 
uncared-for  children  and  those  debilitated  from  disease  between  the 


Fig.  77. — Gangrenous  stomatitis.     Girl,  aged  five  years.      (.Gourtesy  of 
Dr.  R.  C.  Young.) 

ages  of  two  and  twelve  years,  there  is  no  actual  age  limit.  With 
older  persons  it  is  almost  invariably  an  expression  of  some  pathological 
state  of  general  character,  such  as  pernicious  anemia,  leukemia,  tuber- 
culosis, diabetes.  In  one  of  the  author's  cases  of  noma  affecting  a  girl 
nine  years  old  the  characteristic  spirilla  and  fusiform  bacilli  of  Vincent's 
angina  were  found  as  illustrated  and  described  in  connection  with  that 
affection.  Weaver  and  Tunnicliffe  have  previously  called  attention 
to  these  microorganisms  in  noma. 

Symptoms. — -The  following  descriptions  of  examples  from  the 
author's  practice  are  given  as  practical  illustrations  of  the  symptoms 
of  this  disease. 

An  unmarried  man,  aged  twenty-two  years,  until  recently  in  robust 


STOMATITIS  159 

health,  was  referred  by  his  physician,  after  about  two  weeks'  treatment, 
suffering  from  tlie  discharge  of  a  dark  fluid  on  the  distal  side  of  the 
left  inferior  third  molar,  a  temperature  of  10-4°,  not  much  swelling, 
practically  no  pain.  A  dark-colored  spot  formed  on  the  buccal  surface 
of  the  cheek,  which  quickly  extended  until  it  opened  through  the  skin. 
At  no  time  was  there  any  evidence  of  pus.  The  black  gangrenous 
masses  formed  so  rapidly  that  although  cleansed  from  four  to  six  times 
a  day,  the  dead  tissue  could  be  wiped  oft'  with  cotton  swabs  at  each 
attempt.  Germicides  and  other  remedies  seemed  to  have  no  effect 
whatever.  It  was  useless  to  attempt  to  excise  the  dead  tissue,  because 
the  gangrenous  process  began  immediately  at  the  border  of  the  inci- 
sion. Bacterial  examination  showed  staphylococcus  infection.  Not- 
withstanding the  administration  of  stimulating  remedies  and  suitable 


gpv 

^^ 

Fig.  78. — Same  child  shown  in  Fig.  77,  two  and  one-half  days  later.    The  rapid  progress 
of  the  gangrene  may  be  noted. 


nourishment,  the  patient  died  about  ten  days  after  treatment  was 
begun,  and  some  two  or  three  weeks  after  the  onset  of  the  first  symp- 
toms. Death  occurred  through  extension  of  the  gangrenous  process 
to  the  lungs,  black  gangrenous  masses  being  expectorated  during  the 
last  twenty-four  hours. 

Another  case  with  symptoms  of  ulcerative  stomatitis  which  quickly 
extended  until  gangrene  of  the  palate  was  established  is  described 
with  reference  to  leukemia  (page  164),  as  that  proved  to  be  the  under- 
lying cause.  Large  numbers  of  children,  some  of  whose  cases  are 
described  under  the  heading  Necrosis,  page  326,  did  not  reach  the 
author  until  sequestra  of  the  maxillary  bones  requued  removal.  Most 
of  these  gave  histories  of  high  temperatiu-e  and  general  s\'mptoms 
which  were  frequently  confused  with  tj-phoid  and  other  fevers,  wTong 


160  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

diagnoses  being  made  until  finally  the  condition  of  oral  sepsis  was  so 
apparent  that  it  could  no  longer  be  overlooked.  Quite  invariably 
cases  of  this  type  recovered  quickly  after  removal  of  necrotic  tissue, 
local  disinfection,  and  proper  general  care  (Plate  VI,  Fig.  2,  and  Figs. 
77  and  78). 

Prognosis. — With  adults,  when  leukemia,  pernicious  anemia,  or 
similar  blood  disorders  are  the  underlying  causes,  the  prognosis  is  very 
grave  and  a  fatal  termination  is  likely  to  result  through  inability  to 
overcome  the  first  causes  and  the  lack  of  resistance  thus  afforded  in 
combating  the  toxic  effect  of  the  gangrenous  processes. 

In  other  cases  prognosis  is  favorable  except  with  regard  to  cicatricial 
contraction  which  sometimes  results,  and  causes  more  or  less  serious 
deformity. 

Treatment." — Antiseptic  dressings  and  the  excision  of  gangrenous 
tissue  must  be  supplemented  by  measures  designed  to  overcome  the 
underlying  cause  and  to  build  up  the  general  system. 

Antitoxic  serum  in  this,  as  with  other  affections  of  similar  character, 
is  deserving  of  due  consideration,  even  though  its  therapeutic  value 
in  these  cases  is  not  fully  established. 

Parasitic-mycotic  Stomatitis  or  Thrush. — ^This  is  an  affection  which 
occurs  most  frequently  in  nursing  children,  though  occasionally  it  is 
seen  in  adults  after  or  during  acute  processes  or  chronic  diseases.^ 

Etiology. — It  is  a  parasitic  infection  due  to  the  thrush  fungus,  gen- 
erally termed  Oidium  albicans. 

Symptoms. — The  erosions  are  white,  or  creamy  white  in  color,  and 
usually  begin  upon  the  tongue  or  cheek  and  spread  to  the  tonsils, 
palate,  pharynx,  esophagus,  or  lips.  They  may  resemble  flakes  of 
curdled  milk  or  may  become  brownish  from  the  infiltration  of  extrav- 
asated  blood.  It  is  distinguished  from  other  forms  of  stomatitis  by 
the  presence  of  the  fimgus  and  marked  dryness  of  the  mouth  instead 
of  the  reverse  condition  which  usually  accompanies  stomatitis,  espe- 
cially in  infants  and  children. 

Treatment. — The  parasite  seldom  infiltrates  the  epithelium  of  healthy 
individuals.  It  is  therefore  rarely  seen  except  among  ill-nourished  or 
debilitated  children.  The  first  correction  of  hygienic  and  constitutional 
predisposing  causes  should  therefore  be  by  cleansing  the  alimentary 
tract  with  castor  oil  or  small  repeated  doses  of  calomel,  supplemented 
by  bathing,  fresh  air,  and  strict  attention  to  diet.  If  bottle-fed,  as 
such  infants  usually  are,  the  formula  of  the  nourishment  must  be 
properly  adjusted,  bottles,  nipples,  and  other  accessories  thoroughly 
sterilized,  and  the  mouth  swabbed  with  boric  acid  or  other  mildly 
antiseptic  solution. 

Foot-and-mouth  Disease. — Foot-and-mouth  disease  is  a  disease  of 
the  lower  animals,  most  common  among  cattle,  but  believed  to  be 
infectious  to  man. 

1  Coplin:  Manual  of  Pathology,  p.  676. 


STOMATITIS  161 

Etiology. — Brush,  after  careful  study  of  the  review  of  the  Hterature 
of  the  subject,  and  an  exceedingly  painstaking  investigation  among 
dairymen  and  in  communities  supplied  by  herds  having  been  affected 
by  foot-and-mouth  disease,  concludes  that  "there  is  an  aphthous  con- 
dition of  the  young  in  both  the  bovine  and  human  family  which  is  not 
contagious,  and  there  is  an  aphthous  condition  in  both  these  species 
that  is  contagious."  Proof  of  this  is  presented  by  reports  of  cases  of 
children  and  older  persons  who  were  affected  by  aphthous  ulcers  and 
other  more  general  symptoms  of  foot-and-mouth  disease,  after  drinking 
milk  of  cows  at  the  time  suffering  from  the  affection,  and  of  dairy- 
maids who  contracted  herpes  on  fingers  and  toes  from  milking  cows 
having  the  herpetic  eruption  of  this  disease.  The  disorder  is  assumed 
to  be  due  to  the  pathogenic  action  of  an  ultramicroscopic  virus. 

Pathology. — Pathologically  the  disease  is  characterized  by  inflam- 
mation, with  considerable  thickening  of  the  corium,  and  vesicles  from 
the  Malpighian  layer  which  generally  rupture,  exfoliate,  and  cause 
ulcers. 

Symptoms. — There  may  be  many  simple  erosions  without  vesicles, 
or  the  ulcers  may  become  confluent  and  spread  over  considerable  areas 
of  the  surface  of  the  mouth.  In  animals  there  is  often  fever  and  a 
similar  eruption  upon  the  feet.  Usually  the  disease  in  cattle  runs  its 
course  in  about  ten  days,  and  with  humans  in  a  somewhat  shorter 
period,  unless  complications  arise.  Many  instances  are  reported, 
however,  in  which  calves  have  dropped  dead  immediately  after  sucking 
an  affected  mother. 

Treatment. — The  treatment  is  to  stop  the  milk  by  changing  to  that 
of  healthy  animals,  or,  if  uncertain  of  this,  to  boil  the  milk.  Give  local 
treatment  to  relieve  pain  and  other  distressing  symptoms.  Cleanse 
the  intestinal  tract  and  assist  general  support  until  the  symptoms 
have  run  their  course. 

Pseudomembranous  Stomatitis. — Etiology. — This  affection  is  most 
commonly  caused  by  the  Klebs-Loeffler  bacillus,  and  under  these  con- 
ditions is  diphtheria  of  the  mouth.  It  is  generally  agreed,  however, 
that  pseudomembranous  inflaromation  may.be  induced  by  certain 
kinds  of  irritation  without  bacteria,  and  also  that  it  may  result  from 
infection  by  streptococci,  staphylococci,  and  pneumococci  as  a  compli- 
cation of  pneumonia.  Other  bacilli  have  sometimes  been  recognized 
as  exciting  causes.  Notwithstanding  this,  however,  it  is  commonly 
accepted  as  diphtheritic.  Clinicially  this  is  much  the  safer  ground  to 
take  and  regulate  treatment  accordingly. 

Symptoms.^ — iMarked  hyperemia  is  followed  by  exudate  in  the  sub- 
mucosa,  fluid  exudates  and  leukocytes  pass  through  the  surface,  and 
by  necrosis  form  a  grayish-yellow,  dirty  membrane  which  occasionally 
is  quite  dark.  Ulcers  may  form  as  dead  tissue  is  thrown  off.  The 
clearly  defined  outline  indicative  of  the  early  stages  becomes  lost  as 
the  destructive  process  proceeds. 

Treatment. — Injections  of  antitoxin  and  good  general  care. 
11 


162  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

Phlegmonous  Stomatitis.— Phlegmonous  stomatitis^  affects  the  lips 
more  frequently  than  other  portions  of  the  mouth. 

Etiology. — Traumatic  injuries  with  intense  infection  may  be  causes 
or  it  may  be  secondary  to  facial  erysipelas  or  other  cellular  inflanmiation 
of  the  face. 

Symptoms. — The  lips  and  cheeks  become  swollen,  with  tendency  to 
suppuration  and  the  formation  of  abscesses  which  may  rupture  within 
the  mouth.  H\'pertrophy  of  the  deeper  tissues  of  the  lips  sometimes 
follows  a  chronic  form  of  this  infection,  especially  of  the  upper  lip  in 
cases  of  long-standing  coryza  or  eczema. 

Treatment. — Remove  the  cause  if  possible.  Give  general  treatment 
if  necessary  to  restore  healthful  bodily  conditions  and  local  treatment 
by  the  application  of  non-irritating,  antiseptic,  preferably  alkaline 
mouth  washes,  and  upon  the  skin  surfaces  lanoline,  vaseline,  or  other 
suitable  salves  or  dusting  powder  as  may  be  indicated.  In  addition  to 
this,  the  surfaces  of  the  ulcers  "n-ithin  the  mouth  should  be  thoroughly 
cleansed  with  dioxogen. 

Tuberculosis. — Etiology. — Tuberculosis  of  the  mouth  may  occur 
as  a  direct  result  of  primary  infection  of  the  tissues  by  the  Bacillus 
tuberculosis,  or  it  may  be  secondary  to  tuberculosis  of  adjacent  parts, 
or  be  an  extension  from  lupus  of  the  face. 

Ssmiptoms. — Prunary  infection  is  usually  evidenced  by  nodular 
masses  in  the  form  of  papillary  elevations  with  tendency  to  form 
tuberculous  ulcers  which  become  caseous  and  infiltrated  by  tubercles. 

Treatment. — See  Tuberculosis,  p.  103. 

Actinomycosis. — Actinomycosis  (lumpy  jaw)  is  also  a  disease 
common  to  cattle,  horses,  swine,  sheep,  the  dog,  and  other  animals, 
both  domestic  and  wild.  It  affects  the  giuns,  alveolar  and  other  tissues, 
the  mucous  membrane  surfaces  of  the  mouth,  as  well  as  the  tongue 
and  the  maxillary  bones.  As  these  structures  are  usually  jointly 
involved  in  this  aft'ection,  its  full  consideration  is  taken  up  under  Infec- 
tious Diseases,  p.  129. 

Leukemic  Stomatitis. — Leukemic  stomatitis  has  already  been 
referred  to  in  describing  gangrenous  stomatitis,  because  in  acute 
leukemia  the  gums  become  inflamed  and  the  formation  of  ulcers  quickly 
leads  to  necrosis  and  hemorrhagic  inflammation.  The  affected  tissues 
present  much  the  same  appearance  as  in  other  sunilar  conditions.  It 
is  one  of  the  sATnptoms  of  leukemia,  a  disease  of  the  hemogenic  organs 
characterized  by  increase  in  the  number  of  leukoc\i:es  in  the  circulating 
blood,  and  by  pathological  changes  in  the  bone  marrow,  spleen,  and 
hmphatic  glands. 

Detailed  consideration  of  the  nature  and  treatment  of  leukemia  does 
not  properly  come  within  the  province  of  this  work,  but  in  the  diag- 
nosis of  the  form  of  stomatitis,  of  which  it  is  the  underlying  cause, 
its  importance  is  vital.    Both  the  value  of  a  blood  count  in  recognizing 

1  Stengel :  A  Text-book  of  Pathology,  p.  544. 


STOMATITIS 


163 


the  affection  and  the  utter  hopelessness  of  attempted  cure  of  the  mouth 
lesions  by  local  treatment  are  illustrated  by  the  following  description 
of  one  of  the  author's  cases: 


Fig.  79. — Leukemia:  Section  showing  necrosis  of  mucous  membrane  of  tbe  mouth. 


Fig.  80. — Leukemia:     Section  of  the  inner  wall  of  the  cecum,  taken  from  the  same 

individual  as  Fig.  79. 


164 


DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 


A  workman,  aged  fifty-four  years,  married,  of  good  habits  and  family 
history,  so  far  as  could  be  learned,  with  several  healthy  appearing 


Fig.  81. — Leukemia:     Section  of  the  same  case  as  Figs.  79  and  80,  cut  through  the 
muscular  coat  of  the  cecum,  showing  periarteritis  and  thrombus. 


Fig.  82. — Leukemia:     Section  of  spleen,  from  same  case  as  Figs.  79  to  86  inclusive. 


STOMATITIS 


165 


children,  gave  a  history  of  some  months  of  ill  health,  but  was  until 
recently  able  to  work. 


Fig.  83. — Leukemia:     Section  of  liver,  from  same  case  as  Figs.  79  to  86  inclusive. 


Fig.  84. — Leukemia:     Section  of  kidney,  from  same  case  as  Figs.  79  to  86  inclusive. 


166  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

His  anemic  appearance  was  marked,  but  having  formerly  been  of 
rugged  constitution,  he  was  able  to  get  out  of  bed  and  go  about  the 


Fig.  85. — Leukemia:     Section  of  lung,  from  same  case  as  Figs.  79  to  86  inclusive. 


Fig.  86. — Leukemia:     Section  of  heart,  from  same  case  as  Figs.  79  to  86  inclusive. 


STOMATITIS  167 

house  without  assistance.  Examination  of  his  mouth  disclosed  inter- 
stitial gingivitis  chiefly  on  the  lingual  side  of  the  upper  incisors,  with 
gums  and  buccal  mucous  membrane  in  foul  condition  and  tongue 
heavily  coated. 

Every  effort  was  made  to  build  up  the  depleted  system.  Alcohol 
baths,  beef  peptonoids,  bone  marrow,  and  other  nourishing  agents 
were  prescribed,  and  these  supplemented  with  hypodermic  adminis- 
tration of  strychnin,  normal  salt  solution  per  rectum  and  directly  into 
the  tissues,  etc. 

The  last  blood  count  was  as  follows : 

Name.  XonnaL  Present  condition. 

Red  corpuscles       ......  .5,000,000  1,500,000 

Hemoglobin 100  per  cent.  .30  per  cent. 

Corpuscle  index 1  per  cent.  1 . 3  per  cent. 

White  ceUs 7000  105,000 

Polymorphonuclear  uea.rjphiles       .  70  per  cent.  8  per  cent. 

Small  lymphocytes 8  per  cent.  26  per  cent. 

Large  lymphocytes 20  per  cent.  60  per  cent. 

Remnants  of  leukocytes  .      .  *   .      .  25  per  cent.  6  per  cent. 


Megaloblasts 
Normoblasts 


1  to  each  100 
leukocytes 

1  to  each  100 
leukocytes 


Bacteriological  examination  of  the  lesion  showed  staphylococcic 
infections.  Temperature  ranged  from  100°  to  102°,  with  pulse  indica- 
tive of  increasing  muscular  weakness,  both  ranging  higher  toward  the 
last. 

Mental  faculties  were  clear  until  about  forty-eight  hours  before 
death,  which  occurred  about  ten  days  after  the  author  first  saw  him. 

Operation  was  attempted  for  the  purpose  of  removing  the  necrotic 
tissue  that  rapidly  increased  tow^ard  the  end.  An  opening  was  made 
through  the  hard  palate  into  the  nares,  but  the  bone  was  found  to  be 
dead  in  every  direction  so  far  as  it  seemed  advisable  to  remove  it. 
Gangrene  of  the  soft  tissue  was  so  rapid  that  black  masses  were 
removed  at  each  dressing  several  times  daily. 

The  essentially  interesting  feature  of  this  case  is  the  lesson  taught 
by  the  blood  count,  which  indicates  leukemia,  the  microscopic  sections 
of  the  tissues  of  the  mouth  at  the  seat  of  the  oral  affection,  and  others 
of  important  \'isceral  organs,  each  of  which  shows  practically  the  same 
areas  of  inflammation  (Figs.  79  to  86  inclusive). 

Glanders. — Glanders  is  another  disease  of  animals  communicable 
to  man,  which  sometimes  affects  the  tissues  of  the  mouth  and  the 
pharynx.     (For  further  reference  see  p.  134.) 

Etiology. — Glanders  infection  is  caused  by  the  Bacillus  mallei. 
When  involving  only  the  skin  and  adjacent  glands  it  is  called  farcy. 
When  the  mucous  membrane  is  affected,  the  condition  is  termed 
glanders.  Usually  it  is  communicated  to  man  from  the  horse,  although 
it  affects  a  considerable  variety  of  domestic  and  wild  animals.    The 


168 


DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 


bacilli  commonly  gain  entrance  through  some  abraded  or  wounded 
surface  in  the  skin  or  mucous  membrane. 

Pathology. — It  first  appears  in  the  form  of  a  small  nodule  which 
contains  the  almost  pure  leukocytic  infiltrate,  a  few  giant  cells,  and  the 
characteristic  bacilli.  This  increases  and  produces  an  ulcer  which 
usually  results  in  a  series  of  ulcers  that  may  or  may  not  become  con- 
fluent. Extension  through  the  hinphatic  system  sometimes  leads  to  a 
chronic  condition.  In  acute  cases  multiple  abscesses  throughout  the 
body  sometimes  cause  death  from  exliaustion  and  toxemia. 

Diagnosis. — Mallein  is  prepared  from  the  bacilli  and  used  for  diag- 
nostic purposes  in  the  same  manner  as  tuberculin  for  tuberculosis.^ 

Leprosy. — In  common  with  other  diseases  manifesting  themselves 
upon  the  skin  siu-faces,  leprosy  also  affects  the  mucous  membrane  of 
the  moiith.     (See  Leprosy,  p.  139.) 


Fig.  87. — Ludwig's  angina:     Section  through  jaw,  showing  the  ulcerated  condition  of 
the  floor  of  the  mouth  and  other  parts  as  indicated  by  the  Hnes.      (After  Thomas.) 

Ludwig's  Angina  or  Diffuse  Suppuration  of  the  Floor  of  the  Mouth. — 

Diffuse  submaxillary  cellulitis,  or  acute  infectious  submaxillary  angina, 
is  a  septic  condition  affecting  the  tissues  of  the  floor  of  the  mouth. 

Etiology. — Infection  usually  occurs  from  ulcers,  necrotic  conditions 
of  the  mucous  membrane  of  the  mouth,  injuries  to  the  floor  of  the 
mouth  or  extension  of  disease  from  the  pharynx,  lungs,  etc.  The  micro- 
organisms usually  found  are  streptococci,  staphylococci,  pneumococci, 
and  other  pyogenic  bacteria. 

Symptoms. — Ulcers  form  under  and  around  the  tongue;  occasionally 
there  are  abscesses.  Induration  of  the  tissue  sometimes  forces  the 
tongue  upward  and  backward  until  the  swelling  occupies  the  entire 


1  Coplin:   Manual  of  Pathology,  p.  161. 


STOMATITIS 


169 


submaxillary  space.    It  may  extend  downward  into  the  neck  or  involve 
the  pharynx,  larynx,  and  tonsils  (Fig.  87). 

Treatment. — The  treatment  comprises  general  disinfection  of  the 
mouth,  direct  treatment  of  the  ulcers  and  relief  of  the  abscesses  if 
necessary,  hot  applications  to  control  external  swelling  if  this  symptom 
be  present  in  sufficient  degree,  thorough  cleansing  of  the  alimentary  tract 
with  cathartics,  and  treatment  or  removal  of  the  primary  cause,  or  of 
such  irritating  factors  as  may  exist.  In  extreme  cases  tracheotomy  is 
sometimes  required  to  prevent  suffocation  when  the  affected  parts 
are  so  swollen  as  to  interfere  with  normal'respiration.  Nourishment 
per  rectum  is  usually  required  for  the  same  reason  (Fig.  88). 


Fig.  88. 


-Ludwig's  angina:    Shows  characteristic  position  of   head  in  the  effort  of 
respiration.     (Case  of  Dr.  R.  C.  Young.) 


Vincent's  Angina  {Diphtheroid  Angina). — Vincent's  angina  is  an 
inflammatory  lesion  usually  appearing  in  the  mouth  as  an  acute 
stomatitis  or  pharyngitis,  but  most  frequently  as  a  tonsillitis.  A 
pseudomembrane  soon  forms  which  resembles  that  caused  by  the 
diphtheria  bacillus.  At  a  later  stage  ulcers  form  with  well-defined 
borders  not  unlike  sj^philitic  ulceration.  It  most  commonly  affects 
children. 

Etiology. — It  is  believed  to  be  caused  by  a  spindle-shaped  or  fusi- 
form bacillus  accompanying  which  is  usually  found  a  spirilhmi.  (See 
Fig.  89.) 

Treatment. — Unless  complicated  by  other  conditions,  as  not  infre- 
quently occurs,  these  ulcers  yield  readily  to  mild  cleansing  antiseptic 
treatment.  It  sometimes  is  associated  with  diphtheria,  and  aggravates 
this  affection  quite  seriously.  When  it  complicates  cases  of  specific 
fever  Osier  says  it  is  very  fatal.  Weaver  and  Tunnicliffe  have  found 
the  characteristic  spirilla  and  fusiform  bacilli  in  cases  of  noma.  The 
author  also  found  fusiform  bacilli  in  a  case  of  noma  affecting  a  3'oung 


170 


DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 


girl  about  nine  years  old,  with  the  typical  opening  through  the  cheek. 
This  child  died  in  spite  of  every  effort  to  overcome  the  affection,  but 


Fig.  89. — Vincent's  bacillus  with  accompanying  spirochetes. 


r^  . 


"S" 


•-f 
t 


Fig.  90. — Photomicrograph  of  smear  from  the  cheek  of  a  young  girl  with  noma. 
Shows  the  characteristic  spirilla  and  fusiform  bacilli  of  Vincent's  angina.  (Prepared 
by  Dr.  V.  A.  Latham.) 


it  was  impossible  to  say  whether  the  fusiform  bacilli  were  the  real 
factors  in  causation  of  the  disease,  or  only  incidental  for  streptococci 
(see  Fig.  90)  which  were  also  present. 


STOMATITIS  171 

Gonorrheal  Ulceromembranous  Stomatitis. — ^Infection  by  the  gono- 
coccus  of  Neisser  occurs  in  adults,  and  lias  also  been  observed  in  the 
newly  born  and  at  later  periods  of  infancy. 

Etiology. — Menard^  claims  that  gonorrheal  ulceromembranous  stoma- 
titis is  always  secondary  to  profound  systematic  infection,  but  this  is 
opposed  by  many  authorities  and  much  clinical  evidence,  which  leads 
to  recognition  of  direct  local  infection  by  gonococci  as  the  cause. 

Symptoms. — The  symptoms  are  catarrhal  or  mucopurulent  inflam- 
mation, particularly  involving  the  mucosa  of  the  gums  and  cheek. 
Sometimes  a  dirty  gray  coating,  resembling  a  pseudomembrane,  is 
formed. 

S.  M.  Hyman^  reports  the  following  case  of  a  girl,  aged  eighteen 
years:  "She  first  complained  of  terrible  pain  and  burning  in  the  cheeks 
and  mouth.  Intense  pain  caused  by  swallowing  either  liquid  or  solid 
food.  The  mouth  felt  parched;  there  was  foul-smelling  expectoration 
which  contained  traces  of  blood.  Constant  nausea  was  felt.  Uvula, 
soft  palate,  and  cheeks  were  covered  with  a  milky  white  membrane 
with  occasional  bleeding  spbts.  The  membrane  was  non-adherent,  and 
on  removal  showed  a  red  inflamed  surface  resembling  the  scarlatinal 
blush.  The  tongue  was  red,  swollen,  and  painful,  the  patient  being 
unable  to  protrude  it  completely.  The  gums  were  spongy,  markedly 
retracted  from  the  teeth,  and  bled  freely  on  handling.  The  buccal 
temperature  was  99.7°  F.  The  pulse  and  respiration  were  normal. 
The  pseudomembrane  consisted  of  mucous  epithelial  and  pus  cells, 
within  and  around  which  were  groups  of  staphylococci  and  diplococci, 
the  latter  having  all  the  characteristics  of  the  gonococcus  of  Neisser." 

Treatment. — ^The  treatment  described  by  Hyman  in  the  above  case 
is  a  good  example  of  what  the  treatment  of  such  cases  should  be. 
Calomel  in  10-grain  doses  at  bedtime,  daily  applications  of  silver 
nitrate  solution,  1  to  250,  in  the  beginning,  gradually  increasing  to 
1  to  50  as  the  s}iiiptoms  disappeared  (about  the  sixth  day),  gargles  of 
saturated  solution  of  boric  acid  and  alum,  1  to  1000,  were  used  until 
the  cure  was  complete. 

Pemphigus. — Pemphigus  is  an  acute  or  chronic  inflammatory 
disease  of  the  skin,  characterized  by  recurring  eruptions  of  variously 
sized  blebs,  accompanied  by  systemic  disturbance,  and  often  ending 
fatally.  The  mouth  and  other  mucous  membranes  may  become 
involved.  In  the  variety  known  as  pemphigus  vegetans,  the  mouth, 
vagina,  or  other  mucous  membranes  are  usually  first  affected. 

Etiology. — Pemphigus  is  a  rare  disease  and  its  etiology  is  obscure. 
Toxins  derived  from  various  sources  and  acting  on  the  nervous  system 
offer  the  best  explanation  of  its  phenomena. 

Symptoms.- — It  may  be  confined  to  mucous  membrane  surfaces,  or 
the  skin  may  also  be  affected.  Vesicles  form  upon  the  mucous  mem- 
brane of  the  lips,  cheeks,  tongue,  and  palate.     Bullae  may  also  form 

1  Practical  Medicine  Series,  1904,  x. 

2  New  York  Med.  Jour.,  January  25,  1907. 


172  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

in  the  nasopharynx,  esophagus,  conjunctivae,  vagina,  stomach,  and 
throughout  the  intestinal  tract.  Chills,  fevers,  and  other  indications 
of  toxic  disturbances  are  evidenced  under  these  conditions.  Swelling 
of  the  tongue  and  painful  difficulty  in  taking  nourishment  cause 
emaciation. 

Prognosis, — The  prognosis  in  cases  of  this  character  is  grave,  because 
of  the  serious  nature  of  the  primary  causes  and  rapid  loss  of  bodily 
resistance  occasioned  by  difficulty  in  taking  food. 

PIGMENTATION. 

Etiology. — Stengel^  divides  pigmentation  into  four  groups,  according 
to  region  and  variety:  (1)  Those  in  which  the  pigments  are  derived 
from  external  sources;  (2)  those  derived  from  the  hemoglobin;  (3) 
those  derived  from  the  bile ;  (4)  those  derived  from  the  cellular  activity 
within  the  organisms. 

Symptoms.^ — The  manifestations  may  be  local  or  general.  Among 
the  former  are  the  pigmentations  of  nevi  and  moles,  of  pregnancy,  and 
of  the  corpus  luteum,  freckles,  some  scars,  and  certain  skin  diseases, 
as  chloasma  and  xanthelasma,  of  the  lesions  secondary  to  the  more 
cutaneous  parasites,  etc.  The  special  local  type  is  that  seen  in  tumors, 
notably  in  melanosarcomata.  Lipomata  and  sarcomata  (chloromata) 
may  be  analogously  affected.  Among  general  pigmentations  are  those 
of  Addison's  disease,  certain  severe  anemias  and  cachexias,  tubercu- 
losis of  the  peritoneum,  intestines,  and  retroperitoneal  glands,  and 
those  of  abdominal  neoplasms  and  senility.  The  cases  associated  with 
abdominal  lesions  are  held  to  be  connected  with  disturbances  of  the 
adrenal  bodies  or  of  the  splanchnic  sympathetic  system,  which  has 
been  considered  to  have  control  of  pigment  formation.^ 

The  mucous  membrane  of  the  mouth  may  be  affected  in  the  following 
conditions : 

Pneumonokoniosis . — This  is  the  result  of  inhalation  of  dust,  from 
coal,  iron,  stone,  and  vegetable  products.  The  fine  particles  are 
deposited  along  the  bronchial  walls,  and  carried  by  the  phagocytic 
cells  into  the  submucosa  or  by  the  lymphatic  circulation  into  the  peri- 
bronchial, the  mediastinal  glands,  and  deeper  tissues  of  the  lungs 
and  in  rare  instances  to  other  regions  of  the  body.  In  some  cases  the 
mucous  membrane  of  the  lips  and  mouth  becomes  pigmented. 

Argyria. — ^The  skin  and  the  mucous  membrane  of  the  mouth,  gastric 
and  intestinal  walls  sometimes  become  pigmented  as  a  result  of  exces- 
sive ingestion  of  soluble  salts  of  silver. 

Hematogenous  Pigmentation. — This  form  i^  due  to  the  deposition 
of  pigments  derived  from  the  hemoglobin.  In  pernicious  anemia, 
leukemia,  malaria,  severe  cachexias,  in  occasional  infectious  and  septic 
processes,  and  in  various  kinds  of  poisonings,  hemoglobin  is  set  free 

1  Text-book  of  Pathology,  p.  90. 
« Ibid.,  pp.  95  and  96. 


TRAUMA  173 

in  the  circulation  and  results  in  pigmentation.  In  diabetes  and  cir- 
rhosis of  the  liver  and  pancreas,  a  variety  of  hematogenous  pigmen- 
tations occur.  They  vary  in  color  from  a  rusty  red  to  a  dark  black. 
Local  pigmentations  occur  from  thrombosis,  interstitial  gingivitis, 
and  coagulation. 

Hepatogenous  Pigmentation. — In  jaundice  the  bilirubin  and  its 
exudation  product,  biliverdin,  are  deposited  as  pigments,  either  in 
solution  of  granular  precipitations,  or  crystals  in  the  liver,  skin,  mucous 
membrane  and  other  tissues.  The  color,  at  first  yellow,  gradually 
deepens  to  a  deep  olive,  or  may  become  brown  or  greenish. 

Metabolic  Pigmentation. — Pigmentation  derived  from  cellular 
activity. 

Treatment. — Upon  skin  surfaces,  local  pigmentation,  such  as 
nevi,  moles,  etc.,  require  local  treatment  for  their  removal;  but  upon 
mucous  membrane  surfaces  the  treatment  of  all  forms  of  pigmentation 
relates  directly  to  efforts  to  overcome  the  primary  cause  or  general 
condition.  Locally  considered,  the  symptoms  are  chiefly  of  diagnostic 
value  as  evidence  of  the  progress  of  or  recovery  from  general  diseases. 

TRAUMA. 

Traumatic  injuries  to  the  surfaces  of  the  mucous  membrane  of  the 
lips,  cheek,  and  tongue  are  of  much  more  frequent  occurrence  than  is 
generally  recognized,  and  are  often  of  very  great  pathological  impor- 
tance. Nervous  habits,  favored  by  loss  of  teeth,  improper  interproxi- 
mate  spaces  leading  to  the  lodgment  of  particles  of  food  between  teeth, 
sharp  borders  of  exposed  surfaces  of  carious  teeth  or  roots,  malocclusion 
of  teeth,  malformed,  ill-fitting,  imperfectly  constructed  tooth  crowns, 
bridges,  plates,  and  other  dental  work  in  the  course  of  time  are  apt  to 
cause  habits  of  biting  the  cheek  or  lips  or  rubbing  the  tip  or  sides  of 
the  tongue  against  these  roughened  siu"faces.  The  habit  once  acquired, 
such  action  is  performed  subconsciously,  therefore  the  patient  is  con- 
scious only  of  the  fact  that  occasionally  there  are  irritated  or  abraded 
surfaces  upon  the  mucous  membrane  in  these  situations.  Such  chronic 
irritation  occasionally  leads  to  quite  severe  s^Tnptoms  through  infection 
and  other  contributing  factors.  ]\Iore  often,  however,  the  danger 
lies  in  chronic  thickening  of  the  mucous  membrane  surfaces,  which 
make  itself  apparent  in  the  form  of  ulcers,  or  the  mucous  membrane 
in  that  region  may  take  on  the  appearance  of  leukoplakia;  and  under 
such  conditions  there  is  always  likelihood  of  the  occurrence  of  cancer 
in  these  situations.  Nervous  habits  of  the  lips,  jaws,  and  tongue  are 
by  far  too  little  appreciated  in  their  pathological  importance.  In  the 
author's  practice  a  nimiber  of  cases  of  recurrent  swelling  of  the  cheek, 
some  of  them  with  histories  extending  over  a  period  of  several  years, 
for  which  there  appeared  to  be  no  known  cause  and  which  gave  grave 
disturbance,  were  finally  found  to  be  the  result  of  infections  due  to 
irritation  induced  by  cheek  biting.     In  another  case  the  opportmiity 


174  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

for  infection  by  the  tetanus  bacillus  was  brought  about  in  the  same 
manner.  Quite  frequently  benign  ulcers,  diagnosticated  as  cancer, 
have  been  cured  by  remo\-al  of  irritating  tooth  surfaces;  on  the  other 
hand,  many  cases  of  cancer  which  have  passed  beyond  surgical  control 
before  being  properly  diagnosticated,  appeared  to  owe  their  first 
existence  to  chronic  irritation  of  this  character. 

Treatment. — Smooth  rough  tooth  surfaces  in  the  vicinity  of  the 
irritation,  romid  sharp  tooth  borders,  treat  carious  teeth,  and  correct 
such  imperfect  interproximate  spaces  or  other  dental  imperfections  as 
may  be  necessary  to  relieve  the  trouble;  instruct  the  patient  to 
endeavor  to  overcome  the  habit,  apply  tinctiu-e  of  iodin  to  the  irritated 
surfaces  until  acute  inflammatory  symptoms  have  subsided,  and  then 
give  repeated  coating  with  glycerole  of  tannin  to  toughen  and  give 
temporary  resistance  to  the  exposed  surfaces. 

BURNS  AND  SCALDS. 

Etiology  and  Symptoms.^Burns  and  scalds  of  the  lips  and  mouth 
may  occur  from  direct  application  of  heat  or  flame,  from  solutions  or 
drugs,  the  sun's  rays,  electricity,  .r-rays,  etc.  They  are  classified  as 
follows:  First  degree,  erythema  or  congestion  of  skin  stu-faces;  second 
degree,  vesication;  third  degree,  destruction  of  skin  and  deeper  tissues. 

Burns  of  the  mucous  membrane  of  the  mouth  are  most  commonly 
due  to  liquids  that  are  too  hot,  or  drugs  in  sufficient  strength  to  cauter- 
ize and  destroy  the  tissues  with  which  they  come  in  contact.  They 
may  also  be  caused  by  the  inhalation  of  flame  or  hot  steam  or  fumes 
from  burning  chemicals.  In  these  cases  there  is  usually  injury  to  the 
lungs  and  bronchi  also.  Quite  frequently  little  or  no  painful  sensation 
is  experienced  immediately  following  the  inhalation  of  steam,  and  yet 
death  follows  soon  thereafter  as  a  result  of  pulmonary  edema.  A  large 
number  of  the  twenty-one  persons  injured  in  the  accident  to  the 
Twentieth  Century  Limited  train  some  years  ago,  who  inhaled  live 
steam  from  the  burst  pipes,  were  able  to  talk  and  give  their  places 
of  residence  shortly  afterward,  their  only  complaint  being  a  tickling 
sensation  in  the  lungs  and  bronchi.  Yet  one  by  one  they  dropped  dead 
in  the  course  of  a  few  minutes.  The  fumes  of  sulphtu-ic  and  nitric 
acid  in  a  fire  at  ^lilwaukee  brought  death  within  a  very  short  period 
to  a  nimiber  of  firemen  who  inhaled  them. 

Treatment. — ^Vhen  lungs  and  bronchi  are  invohed,  little  can  be  done, 
and  this  only  by  way  of  vapor  and  nebulized  oil  containing  soothing 
alkaline  properties.  If  the  tissues  of  the  mouth  alone  are  involved, 
normal  salt  solution  may  be  freely  used.  Carron  oil,  and  paste  of 
bicarbonate  of  soda  and  oil  may  be  applied  to  the  surfaces.  Pain  can 
to  some  extent  be  relieved  by  the  use  of  a  2  per  cent,  solution  of  cocain 
and  normal  salt.  If  the  burn  has  occurred  from  carbolic  acid  in 
attempted  suicide  or  accidental  injury,  the  immediate  use  of  alcohol 
to  neutralize  and  stop  the  further  destructive  action  of  the  acid  is 


BURNS  AND  SCALDS 


175 


demanded.  ]Milk,  lime-water,  and  bicarbonate  of  soda  are  also  useful 
in  emergency.  Saturated  solution  of  carbonate  of  soda  in  oil,  held  in 
the  mouth  is  a  valuable  agent.  Upon  the  skin  surfaces  of  the  lips  slight 
burns  may  be  coated  with  collodion,  or  dressed  with  saturated  solutions 
of  sodium  carbonate  or  carron  oil  solution.  Picric  acid  on  dressing 
for  five  or  six  days,  followed  by  vaseline  and  lint  and  later  by  a  soothing 
ointment,  gives  good  results  in  ordinary  cases.  Vesicles  as  they  form 
must  be  opened,  shreds  of  tissue  removed,  and  sloughing  surfaces 
relieved  by  touching  with  swabs  dipped  in  dioxogen  followed  by  any 
non-irritating  antiseptics,  such  as  2.5  per  cent,  solutions  of  carbolic 
acid,  which  is  especially  good  for  this  purpose.  With  extensive  burns 
of  other  portions  of  the  body,  the  shock  is  usually  profound,    ^^hen 


Fig.  91. — ^Boy,  aged  fourteen  years, 
burned  in  the  neck  at  the  age  of  three 
years.  Scar  tissue  has  completely  arrested 
growth  in  the  mental  region  of  his  lower 
jaw. 


Fig.  92. — Same  boy  shown  in  Fig.  91 
after  operation.  Removal  of  scar  tissue, 
skin  grafting,  and  the  formation  of  a  chin 
from  soft  tissue  has  effected  the  change. 


they  involve  one-fourth  or  more  of  the  cutaneous  surface,  death  usually 
occurs.  The  extensive  suppuration  which  sometimes  follows  brings 
about  extreme  exhaustion  and  disease  of  the  kidney,  with  quite  frequent 
fatal  result.  In  such  cases  the  best  treatment,  by  all  means,  is  immer- 
sion of  the  body  in  a  normal  saline  solution  bath.  H^-podermic  injec- 
tions of  morphin  are  necessary  to  relieve  the  extreme  pain.  Stimulants 
and  the  application  of  heat  to  body  surface,  wet  packs  of  normal  salt 
or  bicarbonate  of  soda  solution  are  also  useful.  Successes  claimed  for 
"ambrine"  in  the  treatment  for  burns  has  led  to  the  very  general 
adoption  of  various  paraffin  mixtures  in  the  treatment  of  wounds 
and  burns.  ^^  ith  this  protecting  agent  anesthetic  and  antiseptic 
agents  are  sometimes  used.  The  surface  is  dried  with  cotton  pledgets 
dipped  in  ether;  a  coat  of  liquid  petrolatum  applied,  and  over  this  the 


176  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 


Fig.  93. — ^Man,  aged  twenty-one  years,  who  was  burned  in  the  neok  when  three  years 
old.     Scar  tissue  caused  unusual  length  and  thickness  of  lower  jaw. 


Fig.  94. — Same  man  shown  in  Fig.  93  after  oi^eration.  The  lower  jaw  wns  excised 
from  the  bicuspid  tooth  forward  and  a  mental  process  fashioned  out  of  the  thick  jaw- 
bone that  remained. 


ERYTHEMA  177 

warm  paraffin.  The  effect  is  soothing  and  the  repair  of  the  wounds 
facilitated  because  the  paraffin  fihii  does  not  adhere  to  the  injured 
area  and  the  granulations  cannot  penetrate  as  they  do  in  the  meshes 
of  the  dressing  when  gauze  is  applied  directly.  It  is  claimed  that  the 
resulting  scar  is  less  than  by  other  methods. 

Effect  of  Burns. — When  contraction  of  scar  tissue  following  extensive 
burns  results  in  the  destruction  of  the  usefulness  of  the  soft  palate,  a 
plastic  operation,  usually  staphylorrhaphy,  is  necessary  to  restore 
speech  function.  The  effect  of  burns  in  young  children,  involving  the 
lower  portion  of  the  neck  and  face,  may,  by  contraction  of  scar  tissue, 
interfere  with  the  growth  of  the  jaw,  mouth,  and  bones  of  the  face, 
and  cause  marked  deformity.  In  these  cases  much  may  be  accom- 
plished bv  surgical  correction,  and  the  possibilities  for  usefulness  as 
well  as  the  appearance  of  such  individuals  may  be  greatly  improved  by 
the  restoration  of  the  bony  structures,  at  least  approximately  to  normal 
form,  and  by  plastic  operations  upon  the  soft  tissues,  supplemented  by 
skin  grafting.  Two  typical  examples  of  this  are  shown  in  Figs.  91  to 
94,  cases  in  the  author's  practice,  which  illustrate  the  effect  of  burns 
in  early  life,  resulting  in  deformity,  and  the  benefit  of  operation. 


ERYTHEMA. 

Erythema  is  a  hyperemic  skin  disorder,  characterized  by  redness 
in  diffused  or  circumscribed  non-elevated  patches. 

In  common  with  other  skin  eruptions  its  several  forms  give  more 
or  less  manifestation  upon  the  surfaces  of  the  mucous  membrane  of 
the  mouth,  and  the  following  types  deserve  special  mention  in  this 
regard. 

Symptomatic  Erythema. — Symptomatic  erythema  is  a  rash  quite 
commonly  affecting  the  mucous  membrane  as  well  as  skin  surfaces.  • 

Etiology. — It  is  caused  by  disturbances  of  the  general  system  leading 
to  morbid  states.  Drugs  and  certain  foods  thus  affect  individual  cases. 
It  may  precede  or  be  associated  with  variola,  diphtheria,  cholera, 
meningitis,  vaccinia,  etc.  The  chief  importance  of  all  these  classes  of 
erythemata  lies  in  their  resemblance  to  exanthematous  fevers. 

Treatment. — Treatment  is  chiefly  directed  to  correction  of  the  under- 
lying general  cause,  local  use  of  soothing  washes,  and  general  oral 
cleanliness. 

Erythema  Multiforme. — Erythema  multiforme  is  an  acute  disease 
characterized  by  purplish-red  macules,  papules,  and  tubercles  becoming 
vesicular  or  bullous.  These  usually  affect  the  backs  of  the  hands  and 
feet,  although  they  appear  also  upon  the  other  portions  of  the  body 
and  the  mucous  membrane. 

Etiology. — Systematic  disarrangement  leading  to  digestive  disturb- 
ances and  the  absorption  of  toxic  elements  of  the  general  system 
are  the  chief  etiological  factors.  Erythema  iris  and  erythema  nodosum, 
12 


178  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

as  well  as  other  forms  in  which  the  eruption  is  somewhat  similar,  it  is 
generally  agreed  should  properly  be  grouped  together  in  this  class. 

Symptoms. — In  many  cases  the  disease  is  preceded  or  accompanied 
by  rheumatoid  pains,  malaise,  sore  throat,  and  fever.  The  eruption 
develops  rapidly,  and  may  consist  of  macules,  papules,  tubercles, 
vesicles,  blebs,  or  hemorrhagic  lesions,  with  one  or  other  type  of  lesion 
predominating.  x\lthough  usually  most  pronounced  on  the  extensive 
surfaces  of  the  extremities,  any  part  of  the  body  may  be  involved, 
and  at  times  the  mucous  surfaces  of  the  mouth,  eyelids,  nose,  and 
throat  are  affected.    The  lesions  are  of  characteristic  bluish-red  color. 

Treatment. — General  treatment  in  all  such  affections  includes  free 
administration  of  cathartics,  stimulation  of  diuresis  if  necessary,  and 
the  administration  of  suitable  tonics.  Locally,  soothing  washes  and 
lotions  should  be  applied,  and  when  nodules  exist,  especially  lead  lotions. 

Erythema  Endemicum,  Erythema  Pellagrosum,  or  Pellagra.— 
Pellagra  is  an  endemic  trophoneurotic  disease  of  toxic  origin  affecting 
the  nervous  and  digesti^'e  systems  and  producing  characteristic  changes 
of  this  kind. 

Etiology. — The  disease  is  supposed  to  be  due  to  the  eating  of  diseased 
maize. 

It  is  chiefly  found  in  the  countries  of  southern  Europe,  but  within 
recent  years  has  been  very  frequent  in  the  United  States,  especially 
in  the  South. 

Symptoms. — Diarrhea,  dementia,  and  dermatitis  are  the  cardina- 
sjrmptoms.  Recurrent  attacks  of  gastro- intestinal  disturbance,  accoml 
panied  generally  by  various  nervous  symptoms,  result  in  progressive 
physical  and  mental  debility.  The  cutaneous  s\iiiptoms  may  be  a 
marked  feature  of  the  disease,  and  consist  of  erythematous  eruption 
on  the  backs  of  the  hands  and  fingers,  forearms,  face,  neck,  upper  chest, 
and  dorsum  of  the  feet,  resembling  "sunburn."  This  is  succeeded  by 
a  stage  of  thickening  and  pigmentation,  and  still  later  atrophy  of  the 
skin  occurs.  In  most  cases  some  degree  of  stomatitis  is  found  which 
may  be  sufficiently  intense  to  resemble  an  advanced  stage  of  mercurial 
stomatitis.  The  entire  buccal  mucosa  is  then  bright  red  and  denuded 
of  epitheliimi,  the  gums  are  swollen  and  show  aphthous  ulcers,  while 
the  tongue  is  brightened  with  enlarged  papillse. 

Pellagra  pursues  a  variable  course  and  may  recur  annually  for 
several  years.  Its  mortality  is  high,  the  final  stage  being  one  of 
marasmus. 

Treatment. — Good  hygiene  and  nutritious  food  are  important. 
Lombroso  recommends  arsenic  internally.  Salvarsan  has  been  tried 
without  success.  Transfusion  has  recently  given  some  favorable 
results. 

URTICARIA. 

Urticaria  is  an  affection  characterized  by  the  development  of  wheals 
which  are  accompanied  by  burning  and  itching  sensations. 


LICHEN  PLANUS  179 

Etiology. — The  general  causes  are  gastro-intestinal  derangements, 
quite  frequently  due  to  a  great  variety  of  foods  or  idiosyncrasy  with 
regard  to  special  food,  drugs,  intestinal  worms,  malaria,  affections  of 
of  the  generative  organs,  chronic  disorders  of  the  stomach,  bowels,  and 
kidneys,  or  of  the  brain  and  spinal  cord. 

Local  irritations,  such  as  insect  bites,  coarse  underwear,  etc.,  may  be 
exciting  factors. 

Symptoms. — There  may  be  only  a  few,  or  large  numbers  of  wheals 
may  appear  suddenly  and  remain  for  a  few  minutes  or  several  hours, 
then  disappear  in  the  same  abrupt  manner.  The  skin  is  usually  affected, 
but  mucous  membrane  surfaces,  the  mouth,  pharynx,  respiratory  tract, 
and  stomach  may  also  be  implicated.  In  acute  cases  there  are  only 
one  or  two  outbreaks ;  in  the  chronic  form  successive  attacks  may  occur 
during  an  indefinite  period. 

Treatment. — Treatment  should  be  directed  to  elimination  of  dis- 
turbing food,  correction  of  stomach  or  other  disorders,  general  cleansing 
of  intestinal  tract. ^  Ice  held  in  the  mouth  and  soothing  washes  are 
beneficial. 

HERPES  SIMPLEX. 

Herpes  facialis  is  commonly  called  fever  blisters. 

Etiology. — It  is  associated  with  febrile  disorders,  though  it  may 
result  from  gastro-intestinal  disturbance  or  local  irritation. 

Recurring  forms  are  frequently  seen  in  syphilitic  patients,  and  may 
be  confounded  with  relapsing  mucous  patches. 

Symptoms. — This  form  of  the  affection  usually  appears  upon  the 
lips,  angle  of  the  mouth,  and  lower  part  of  the  face.  It  also  quite 
commonly  affects  the  mucous  membrane  of  the  mouth. 

Treatment. — Flexible  collodion  or  other  non-irritating  coating  to 
protect  from  irritation  and  rupture  is  useful.  Attention  should  be 
paid  to  the  underlying  general  condition. 

LICHEN  PLANUS. 

A  disease  of  the  skin  characterized  by  red  or  bluish-red,  angular, 
flat,  shining  umbilicated  papules,  usually  affecting  the  anterior  sur- 
faces of  the  forearm,  and  on  subsidence  leaving  pigmentation. 

This  eruption  develops  gradually,  the  lesions  tend  to  group,  and 
large  areas  of  skin  may  be  affected.  It  is  not  unusual  to  find  the 
disease  upon  the  mucous  membrane.  In  these  cases  it  occurs  most 
often  in  the  mouth,  the  frequency  of  affection  of  the  anus,  urethra, 
and  larynx  decreasing  in  the  order  given. 

Etiology. — Lichen  planus  is  nearly  always  of  neurotic  origin,  although 
digestive  disturbances  seem  causative  in  some  cases. 

Symptoms. — Lieberthal  gives  the  following  description  of  lichen 
planus  as  it  appears  in  the  oral  cavity: 

1  Hare:     System  of  Practical  Therapeutics,  pp.  56  and  57. 


180  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

"On  the  cheeks,  lichen  planus,  as  a  rule,  affects  that  part  which  is 
just  opposite  the  interdental  space  and  presents  papules,  oval  or 
circular  plaques,  and  most  frequently  streaks  or  linear  projections 
with  intervening  furrows.  These  projections  are  arranged  in  different 
ways,  parallel  to  each  other,  convergent  or  divergent,  passing  each 
other  in  different  directions  and  forming  networks  or  stellar  or  brush- 
like formations.  They  all  show  the  character  of  the  elementary  papules, 
are  opaline,  sharply  defined,  and  painless. 


Fig.  95. — Lichen  planus.      (After  Schaniberg.) 

"The  lesions  of  the  tongue  differ  somewhat.  On  the  back  they 
present  irregular,  oval,  or  circular  plaques,  while  on  the  upper  and 
lower  surfaces  of  the  margins  solitary  papules  are  found,  or,  more 
frequently,  irregular  or  band-  and  stripe-like  plaques.  All  these  differ 
from  the  lesions  of  the  cheeks.  They  are,  as  a  rule,  not  sharply  defined, 
are  smooth,  less  hard,  not  raised  above  the  level  of  the  normal  surface, 
not  glossy,  but  dull  and  grayish  white.  On  the  mucous  membrane  of 
the  lips,  the  papules  form  irregular  plaques,  and  on  the  vermilion 
border  groups  of  irregular  plaques. 


PLATE    VII 


FIG.    1 


Lichen  Planus. 


Leukoplakia. 


PLATE  VIII 


Leukoplakia. 


FIG.   2 


Mucous  Patch. 


LEUKOPLAKIA  181 

"On  the  soft  and  hard  palates,  and  on  the  gums,  solitary  and  aggre- 
gated papules  are  more  frequent  than  plaques  or  networks.  On  the 
tonsils  the  more  solitary  lesion  prevails.  As  mentioned,  the  older  the 
process  upon  the  mucous  membranes,  the  more  do  the  papules  coalesce 
and  lose  their  distinct  outlines,  until  the  elementary  lesions  cannot 
be  recognized  as  such.  The  plaques  and  streaks  lose  to  a  great  extent 
their  roughness  and  hardness,  and  at  last  they  become  so  flat  that  there 
is  no  elevation  present,  but  only  the  shiny  white  discoloration  resem- 
bling mucosa  touched  with  silver  nitrate.  These  lesions  show  no  ten- 
dency to  degenerative  changes;  no  erosion  or  ulceration  occurs.  The 
anatomy  is  similar  to  that  of  the  lesions  of  the  skin"  (Fig.  95).    (Plate 

VII,  Fig.  1.)  .  ,       .  u 

The  mucous  membrane  lesions  of  lichen  planus  are  often  only  with 
difficulty  distinguished  from  those  of  syphilis,  and  inasmuch  as  lichen 
planus  is  also  favorably  influenced  by  mercury  the  therapeutic  test 
is  of  no  value. 

Treatment.— Arsenous  acid  in  steadily  increasing  doses  and  regu- 
lation of  diet  are  suggested.  Local  applications  are  not  required. 
Salicylate  of  soda  is  sometimes  efficient  in  cases  where  arsenic  does  not 
give  favorable  results.  Protiodide  of  mercury  is  of  distinct  value  in 
many  cases. 

LEUKOPLAKIA. 

Leukoplakia  Buccalis,  Leukokeratosis  Buccalis,  Leukoma,  Leuko- 
plasis. — This  is  a  disease  of  the  mucous  membrane  of  the  mouth.  It 
may  appear  upon  the  surface  of  the  palate,  gums,  cheeks,  but  occurs 
most  frequently  upon  the  lips  and  tongue,  and  is  characterized  by  white 
or  bluish-white  plaques  or  patches  (Plate  VH,  Fig.  2,  and  Plate  VIII, 
Fig.  1). 

Etiology  and  Pathology.— Syphilis  has  been  held  to  be  a  frequent 
etiological  factor,  and  of  this  form  the  plaques,  opaline  or  milky- 
white  patches,  have  been  held  to  be  pathognomonic  (Plate  VIII, 
Fig.  2).  Recent  writers,  however,  incline  to  the  belief  that  sji^hilis 
is  not  frequently  a  direct  cause.  Since  it  affects  males  almost  exclu- 
sively and  after  the  age  of  thirty,  and  because  excessive  use  of  tobacco 
has  been  found  to  be  an  almost  constantly  associated  condition  in  such 
cases,  this  and  local  irritation,  coincident  with  the  use  of  strong  spirit- 
ous  liquors,  hot  fluids,  and  hot  or  highly  spiced  foods,  together  with 
digestive  disturbances  and  conditions  of  the  gastro-intestinal  tract, 
due  to  faulty  metabolism  and  the  effect  of  hypo-  or  hyperacid  con- 
ditions of  the  body,  are  the  chief  causes.  Local  irritation  from  abrasion 
by  rough,  carious,  or  otherwise  improperly  cared  for  teeth;  ill-fitting 
crowns,  plates,  or  dental  bridge-work,  have  also  been  recognized  as  of 
etiological  importance.  But  in  the  opinion  of  the  author,  by  far  the 
most  unportant  factor  may  be  included  under  the  general  description 
"nervous  mouth  habits."  (See  page  173.)  All  of  the  factors  enumer- 
ated \^ould  predispose  to  nervous  conditions  of  the  jaw.     Constant 


182  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

pressure  or  rubbing  of  the  tongue  upon  roughened  or  uneven  surfaces 
in  the  mouth,  the  biting  of  the  cheeks  or  Hps,  and  various  other  habits 
of  hke  character  are  subconsciously  indulged  in,  in  one  form  or  another, 
by  large  numbers  of  people  and  undoubtedly  account  for  irritation  by 
roughened  surfaces  in  this  affection,  even  as  they  do  for  other  local 
manifestations  of  disease.  The  marked  tendency  to  carcinoma,  which 
has  been  so  frequently  noted  in  such  cases,  has  led  to  the  association 
of  leukoplaques  with  true  leukoma  which  is  distinctly  carcinomatous 
in  character. 

Symptoms.- — Usually  the  affection  is  not  recognized  until  the  white 
appearance  is  more  or  less  fully  developed,  although  in  its  initial  stage 
the  patches  are  slightly  red.  The  circumscribed  areas  later  become 
white  or  bluish  white,  radiating  or  oval,  and  by  coalescence  tend  to 
become  large.  At  this  stage  the  surface  is  glistening  and  raised  above 
the  surrounding  membrane,  and  though  large  surfaces  may  be  covered, 
they  quite  frequently  pass  unnoticed,  on  account  of  the  fact  that  they 
are  not  sensitive  at  this  stage.  With  progress  of  the  disease  the  surfaces 
become  hardened,  discolored,  dry,  rough,  and  by  thickening  of  the 
epithelial  covering  more  or  less  raised.  This  roughened  or  cornified 
layer,  as  the  thickening  progresses,  becomes  loosened  at  the  edge. 
Upon  accidental  or  other  removal  of  this  thickened  epithelium,  the 
under  or  interlying  surface  is  exposed  and  found  to  be  smooth,  red,  and 
highly  sensitive.  Occasionally  there  is  tendency  to  bleed.  At  this 
time  there  may  be  acute  sensitiveness  to  irritation,  with  a  burning,  dry 
sensation.    ^Marked  fissures  and  furrows  may  develop  upon  the  tongue. 

Hypertrophy  of  the  papillae  sometimes  gives  a  warty  appearance, 
ulcers  ultimately  form,  and  from  this  usually  cancer  of  the  tongue 
originates. 

Prognosis. — The  prognosis  is  serious  only  insofar  as  there  is  danger 
of  carcinoma  developing,  as  it  so  frequently  does  on  leukoplakic  surfaces. 

Treatment. — The  treatment  consists  in  removal  of  local  causes  of 
irritation,  including,  if  possible,  correction  of  nervous  habits  by  which 
such  irritation  is  provoked.  Attention  should  be  paid  to  improvement 
of  both  local  and  general  hygienic  conditions.  Abstinence  from  or  at 
least  marked  limitation  in  the  indulgence  in  alcohol,  tobacco,  or  other 
forms  of  dissipation  are  recommended. 

Cauterization  and  the  use  of  escharotic  drugs  by  direct  application 
should  be  avoided  on  the  ground  that  they  tend  to  increase  rather 
than  diminish  the  trouble. 

Surgical  removal  of  the  mucous  membrane  over  the  affected  area  is 
sometimes  required, 

ECZEMA. 

Eczema  is  an  inflammatory  disease  of  the  skin,  with  diffuse  redness 
and  exudation,  or  with  papules,  vesicles,  or  pustules,  followed  by  weep- 
ing or  scaling,  and  usually  accompanied  by  much  itching.^ 

'  National  Medical  Dictionary,  p.  49. 


PLATE    IX 


FIG.    1 


Seborrheic    Eczema. 

FIG.    s 


Herpes   Labialis. 


PURPURA  183 

This  affection  according  to  Scharaberg/  constitutes  about  30  per 
cent,  of  all  of  the  skin  diseases,  and  is  met  with  at  all  ages  and  conditions 
of  life.  One  of  its  many  forms,  eczema  labialis,  touches  the  field  of 
our  present  consideration. 

Eczema  Labialis. — Eczema  labialis  is  a  small  pustular  form  of 
eczema  which  affects  the  lips  (Plate  IX,  Fig.  2). 

Etiology. — Its  causes  are  local  irritations,  and  constitutional 
influences  due  to  alimentary  disorders,  auto-intoxication,  gouty  and 
rheumatic  diathesis,  functional  disorders,  and  affections  of  the  nervous 
system. 

Treatment. — Schamberg  states  that  eczema  of  the  vermilion  border 
of  the  lips  often  runs  an  obstinate  course,  and  advises  the  use  of 
lotions  of  resorcin,  boric  acid,  or  ointment  of  salicylic  and  boric  acids 
in  cold  cream.  In  chronic  cases,  weak  solutions  of  nitrate  of  silver 
and  caustic  potash.  General  treatment  and  hygienic  measures  should 
be  adopted  for  correction  of  the  constitutional  causes.  The  following 
formula  is  recommended: 

I^ — Resorcini, 

Acidi  borici aa  3j 

Olein  amygdal.  dulcis    .  ...  fgij 

Aquse  calcis .  .       .  i^iv 

Pulv.  zinci  oxidi [3iv — M. 

PURPURA. 

Purpura  is  manifested  by  red  or  purple  hemorrhagic  patches  upon 
the  skin  A\"hich  do  not  disappear  upon  pressure.  These  are  usually 
symptoms  of  an  infectious  eruptive  disease,  such  as  smallpox,  scarlet 
fever,  measles,  cerebrospinal  meningitis,  malaria,  diphtheria,  and 
similar  affections.  Under  such  conditions  there  is  usually  a  more  or 
less  characteristic  and  somewhat  similar  affection  of  the  mucous  mem- 
brane of  the  mouth.  It  may  also  appear  ^^■ithout  the  association  of 
infectious  diseases.  Of  its  several  forms,  purpura  hemorrhagica  is  of 
special  importance  to  our  subject. 

Purpura  Hemorrhagica. — Etiology. — It  is  caused  by  many  different 
kinds  of  toxic  influences  acting  through  the  circulation  or  upon  the 
vessel  walls.  These  are  not  alone  those  incident  to  infectious  diseases, 
but  the  poisons  of  many  different  kinds  of  drugs,  either  by  reason  of 
individual  susceptibility  or  other"^ise,  may  also  produce  similar  erup- 
tions, as  do  also  the  autotoxins  and  imperfect  metabolism.  It  is  some- 
times an  evidence  of  organic  disease. 

Symptoms. — There  is  usually  languor,  headache,  and  fever.  Hemor- 
magic  spots  of  varying  size  appear  upon  the  skin,  and  petechise  on 
rhucous  membrane  surfaces  with  tendency  to  hemorrhage  of  the 
mouth,  nose,  and  other  parts  covered  by  mucous  membrane.  The 
period  of  its  duration  is  uncertain,  but  in  the  fulminating  form,  when 
due  to  intense  septic  or  toxic  influence,  rapid  death  results. 

1  Diseases  of  the  Skin  and  Eruptive  Fevers. 


184  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

Prognosis. — In  purpura  hemorrhagica  the  prognosis  is  more  uncertain 
than  in  other  forms,  because  of  the  possibility  of  its  being  an  indication 
of  some  grave  underlying  disease  and  the  likelihood  of  fatality  resulting 
through  internal  hemorrhage. 

Treatment.- — Support  and  stimulate  the  patient  to  assist  natural 
resistance.  Give  easily  digested,  highly  nourishing  diet,  good  hygienic 
care,  alcohol  baths.  Keep  patient  in  bed.  Give  rest  and  quiet.  Use 
astringent  mouth  washes.  Coat  the  gums  and  other  affected  surfaces 
of  the  mucous  membrane  of  the  mouth  with  tincture  of  iodin.  When 
hemorrhage  of  internal  parts  is  so  persistent  as  to  become  a  menace 
and  refuses  to  yield  to  administration  of  ergot  and  remedies  of  similar 
character,  it  is  the  belief  of  the  author  that  the  transfusion  of  blood 
from  a  normal  individual  is  the  most  efficient  way  to  prevent  fatal 
termination  (see  p.  41). 

Scorbutus,  Scurvy,  Sometimes  Called  Purpura  Nautica. — Scorbutus 
is  a  disease  affecting  the  blood  and  general  system,  and  is  due  to  the 
absence  of  certain  articles  of  diet.  It  has  been  recognized  from  the 
very  earliest  ages  by  frequent  historical  reference.  INIodern  methods 
have  made  possible  the  preservation  of  vegetable  foods,  and  for  this 
reason  it  is  now  rarely  met  with. 

Symptoms. — Mental  depression,  marked  and  progressive  emaciation, 
hemorrhagic  spots  on  the  skin,  and  tendency  to  hemorrhage  of  the 
nasal,  buccal,  and  pharyngeal  mucous  membrane  surfaces,  with  spongy 
and  bleeding  gums,  indicative  of  interstitial  gingivitis,  are  among  the 
symptoms.  There  is  usually  chronic  diarrhea  with  pain  in  the  joints 
and  also  neuralgic  affections. 

Diagnosis. — On  account  of  the  similarity  of  symptoms  it  is  some- 
times necessary  to  make  careful  differential  diagnosis  between  purpura 
hemorrhagica  and  scorbutus.  This  has  been  summed  up  by  Schamberg 
in  the  following  form : 

SCORBUTUS.  PURPURA  HEMORRHAGICA. 

1.  Occurs  in  those  subject  to  lack  of  vegetable         1.  No  such  etiological  relationship. 

food  and  to  bad  hygiene. 

2.  Definite  antecedent  symptoms:  weakness,  2.  Antecedent  signs  slight  or  absent. 

impaired  circulation,  etc. 

3.  Onset  slow.  3.  Onset  sudden. 

4.  Gums  spongy,  swollen,  and  bleeding;  teeth         4.  Gums    often    bleeding,    but    not 

loose.  swollen. 

5.  Severe  muscular  pain.  5.  Less  marked. 

6.  Brawny   infiltration  of  lower  extremities.  6.  Not  present. 

7.  Hemorrhages    from    mucous    membranes,  7.  Hemorrhages  from  mucous  mem- 

not,  as  a  rule,  profuse.  brane  may  be  so  severe  as  to 

prove  fatal. 

Treatment. — Its  treatment  should  be  preventive,  by  proper  regula- 
tion of  the  diet  whenever  conditions  are  such  as  to  favor  its  occurrence. 
Cure  may  be  effected  by  dietetic  correction,  through  the  addition  to 
the  dietary  of  potatoes,  pickles,  lime  juice,  vinegar,  citric  acid,  etc. 
Rubbing  the  body  and  particularly  stiffened  joints  with  olive  oil  is 
also  beneficial.    Local  treatment  consists  of  thorough  cleansing  of  the 


PURPURA  185 

teeth,  particularly  their  necks  and  exposed  root  surfaces  and  the 

application  of  tincture  of  iodin. 

Infantile  Scorbutus. — This  disease  is  sometimes  also  called  Barlow's 
disease,  and  some  writers,  notably  Schubert,'  make  an  effort  to  dis- 
tinguish between  the  two  diseases.  It  is  a  form  of  scurvy  affecting 
infants.  Because  of  its  resemblance  to  other  infantile  affections  it  has 
only  been  generally  recognized  during  comparatively  recent  years. 

Morse-  states  that  when  of  mild  form  it  is  overlooked  and  mistaken 
for  difficult  dentition.  Among  the  thirty  infants  he  examined  the 
trouble  had  been  diagnosticated  as  rickets,  Pott's  disease,  hip  disease, 
periostitis,  gout,  s^'philis  of  the  cord,  acute  nephritis,  uric  acid  diathesis, 
and  arsenic  poison. 

X.  Jacobson^  believes  infantile  scurvy  to  be  more  frequently  over- 
looked than  any  other  pathological  condition  of  childliood.  Cases  have 
been  reported  in  which  this  affection  has  been  mistaken  for  periostitis, 
osteomyelitis,  and  osteosarcoma,  and  because  of  erroneous  diagnosis 
operations  have  been  undertaken  for  the  removal  of  conditions  which 
did  not  exist. 

Among  the  early  valuable  contributions  to  this  subject  we  find  an 
article  "Two  Cases  of  Infantile  Scorbutus,"  by  Dr.  Edward  C.  Kirk, 
of  Philadelphia,  published  in  the  Dental  Cosmos  of  June,  1895.  Kirk 
recognized  the  true  cause  of  this  affection  through  his  study  of  faulty 
metabolism,  and  his  interest  was  excited  by  a  case  of  Dr.  J.  AV.  ^^  hite's 
that  came  under  his  observation,  which  he  reports  in  coimection  with 
one  of  his  own  patients.  Both  these  cases  and  others  presented  by  more 
recent  writers  are  described  in  detail  below  to  give  a  proper  basis  for 
comparison  of  sjTnptoms. 

Etiology. — ^The  disease  is  generally  recognized  as  a  form  of  mal- 
nutrition due  to  either  excess  or  insufficiency  of  certain  food  elements, 
producing  changes  in  the  blood  in  infants  similar  to  those  long  recog- 
nized as  indications  of  scurvy  in  adults.  Authors,  however,  differ  as 
to  the  exact  nature  of  the  exciting  causes. 

Stoles^  attributes  it  "to  the  distribution  of  the  ferments  in  the 
milk,"  and  Cohns  to  disturbance  in  absorption  of  calcium.  Certain 
authors  see  no  connection  between  the  disease  and  sterility  of  the 
food,  but  regard  it  as  a  manifestation  of  auto-intoxication  in  chronic 
dyspepsia.  It  is  generally  agreed  that  an  important  factor  is  the  use  of 
proprietary  foods  in  feeding  infants. 

Kirk  says:  "There  is,  however,  an  important  side  to  this  matter 
of  infant  nutrition,  not  by  any  means  so  clearly  manifest,  but  which 
careful  investigation  will,  I  think,  prove  to  be  a  definite  outgro\\i:h  of 
the  pernicious  custom  of  depending  altogether  upon  proprietary  and 
chemical  laboratory  food  products  for  the  nourishment  of  infants.    I 

1  Deutsch.  Arch.  f..klin.  Med.,  December  13,  1905. 

*  Med.  Rec,  October  19,  1907. 

'  Xew  York  Med.  Jour.,  December  11,  1909. 

*  Practical  Medicine  Series,  Pediatrics,  1908,  ^-ii. 


186  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

refer  to  the  systemic  nutritional  disorders  so  often  produced  by  this 
custom.  Disorders  of  the  digestive  tract,  with  their  sequeLne,  are 
sufficiently  familiar;  they  do  not  only  give  rise  to  a  number  of  acute 
and  chronic  pathological  conditions,  but  indirectly  bring  about  impair- 
ment of  nutrition  through  the  inability  to  properly  prepare  and  assimi- 
late food.  This  train  of  evils  can  be  shown  to  be  more  closely  connected 
with  the  indiscriminate  use  of  artificially  prepared  foods  in  many 
instances  than  the  properties  of  the  preparations  would  be  willing  to 
admit.  But  a  special  feature  which  constitutes  an  important  objec- 
tion to  the  habitual  use  of  these  preparations  is  one  which  directly 
affects  the  nutritional  process,  viz.,  their  inadequacy  to  supply  all  the 
elements  necessary  for  the  normal  nutrition  of  the  individual.  Two 
closely  allied  conditions  directly  due  to  imperfect  nutrition,  from  lack 
of  essential  food  elements,  are  rickets  and  scorbutus." 

Schubert  states,  "the  latter  (Barlow's  disease)  affecting  infants, 
has  been  attributed  to  the  use  of  sterilized  cows'  milk."  Griffith  has 
seen  cases  which  occurred  in  infants  nursed  by  their  mothers,  and  which 
recovered  by  the  use  of  sterilized  cows'  milk. 

The  author  has  known  infants  to  die  of  inanition  who  nm-sed  the 
breasts  of  mothers  with  an  abundance  of  milk  which  evidently  did  not 
contain  all  of  the  necessary  food  elements  in  proper  distribution. 

This  seems  to  be  the  essential  point.  While  artificial  foods  and 
even  modified  milk  products  are,  as  a  matter  of  necessity,  less  perfect, 
and  bottle  infants  therefore  more  prone  to  all  forms  of  digestive 
nutritional  affections,  the  disease  may,  nevertheless,  occur  in  individual 
cases  when  the  mother's  milk  is  insufficient. 

Symptoms.- — The  onset  of  scurvy  is  slow.  There  is  a  general  appear- 
ance of  malnutrition,  such  as  anemic  emaciated  appearance,  with 
restlessness  and  evidence  of  irritability.  The  gums  over  unerupted 
teeth  and  around  those  that  are  already  erupted  become  spongy, 
swollen,  dark  in  color,  with  marked  tendency  to  bleed.  Teeth  become 
loosened  and  are  sometimes  lost.  As  the  disease  progresses  the  maxil- 
lary bones  become  involved,  causing  necrosis  as  with  other  forms  of 
scurvy.  There  is  a  noticeable  tenderness,  especially  of  the  legs,  which 
gradually  increases  until  the  use  of  the  legs  is  lost.  Subperiosteal 
hemorrhages  sometimes  occur  and  also  circumscribed  hemorrhage,  in 
which  separation  of  the  epiphysis  causes  severe  pain.  Hemorrhagic 
swelling  of  the  eyelid  with  or  without  exophthalmos  is  sometimes  an 
important  symptom. 

Hemorrhages  may  occur  over  the  bones  of  the  skull,  giving  the 
face  an  expression  of  abject  terror,  and  also  in  the  skin  and  roof  of  the 
mouth  as  well  as  the  eyelids  and  intestinal  walls.  Usually  there  is  no 
fever,  but  cases  have  been  reported  with  temperatures  as  high  as 
105°  F. 

Description  of  Cases. — Since  recognition  of  the  symptoms  is  the 
element  of  vital  consequence,  especially  to  dentists  and  oral  surgeons, 
because  of  important  indications  appearing  in  the  mouth,  the  author 


PURPURA  187 

gives  full  descriptions  of  cases  to  facilitate  comparison  and  to  impress 
the  important  features. 

Edicard  C.  Kirk's  Cases. — "About  six  years  ago  I  was  asked  by  the 
late  Dr.  J.  W.  White  to  see  a  case  under  his  care  which  presented  a 
remarkable  and  unusual  condition  of  the  gums.  The  patient  was  an 
infant  girl  of  about  ten  months,  the  child  of  well-to-do  parents,  sur 
roinided  by  all  the  conveniences  and  comforts  of  living  that  ample 
means  and  intelligence  could  procure.  The  child  had  been  weaned 
at  about  two  months,  owing  to  some  imperfection  in  the  quality  of  the 
mother's  milk,  and  had  been  artificially  fed  with  great  care  under 
intelligent  medical  direction  from  that  period.  A  short  time  before 
I  saw  the  case,  about  two  or  three  weeks  as  I  now  recollect  it,  the  child 
had  shown  SAinptoms  of  ill  health,  becoming  pale,  somewhat  emaciated, 
restless  and  irritable,  especially  at  night,  with  a  tendency  to  cr}^  out  in 
its  sleep,  which  was  more  or  less  broken  and  fitful.  Later,  the  mother 
noticed  a  marked  loss  of  power  in  the  lower  limbs,  which  at  first  the 
attending  physicians  wer^  inclined  to  regard  as  a  mere  fancy  on  the 
part  of  the  anxious  mother,  but  the  observation  was  later  confirmed, 
when  almost  total  paralysis  of  the  lower  limbs  ensued;  there  was, 
however,  apparently  no  loss  of  sensation.  There  were  no  pathological 
manifestations  upon  the  skin,  swellings  or  ecch^'moses  upon  any  part 
of  the  body,  so  far  as  I  could  learn.  An  examination  of  the  mouth 
revealed  a  most  distressing  state  of  affairs.  The  incisors  of  both  jaws 
were  fully  erupted,  and  were  apparently  standing  in  their  alveoli 
without  the  least  particle  of  attachment  of  gmn  to  them.  The  gingival 
border  had  receded  froQi  the  teeth  for  at  least  a  line  in  distance,  and 
presented  a  thickened  necrotic  edge,  highly  vascular,  and  bleeding 
at  the  slightest  touch.  Over  the  position  of  each  of  the  first  molars 
was  a  vascular  tumor,  the  size  of  a  half-cherry,  and  it  in  fact  closely 
resembled  one  of  the  small  and  dark-colored  cherries  in  appearance. 
Upon  passing  a  bistoury  into  these  vascular  tumors  a  considerable 
flow  of  dark,  apparently  disorganized  blood  took  place,  and  the  erupting 
molar  could  be  felt,  and  later  seen  at  the  bottom  of  the  spongy  vascular 
mass  which  surrounded  it.  The  bone  of  the  alveolar  border  surround- 
ing the  incisors  w^s  denuded  so  that  it  could  be  distinctly  seen  and  felt 
with  an  instrument.  The  teeth  were  so  loose  that  it  seemed  almost 
certain  that  they  would  soon  be  thro^^^l  out  of  their  sockets  from  loss 
of  their  attachment.  The  case  had  been  examined  by  a  number  of  the 
most  experienced  and  reliable  physicians  of  Philadelphia,  without 
having  arrived  at  a  satisfactory  diagnosis,  and  the  treatment  was 
largely  upon  the  expectant  plan,  with  the  endeavor  to  combat  the 
several  pathological  manifestations  as  they  arose.  One  specialist  had 
diagnosticated  the  case  as  purpura,  another  as  of  metallic  poisoning. 
The  former  diagnosis  was  found  to  be  erroneous,  because  none  of  the 
general  symptoms  of  the  disease  subsequently  developed,  while  the 
mouth  conditions  grew  gradually  worse."  Change  of  air  and  diet 
resulted  in  the  complete  recovery  of  the  case. 


188  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

Dr.  Kirk  describes  another  one  of  his  cases  as  follows:  "The  onset 
of  the  attack  on  the  incisor  region  was  sudden.  There  appeared  in 
less  than  two  days  a  large,  pendulous,  dark  red,  vascular  tumor  from 
the  palatal  gingival  border  of  the  superior  incisors,  which  hung  down 
below  their  cutting  edges,  and  interfered  with  closure  of  the  jaws.  A 
corresponding  mass  developed  in  relation  to  the  lower  incisors.  It  was 
noticeable  in  this  case  that  areas  of  ecchAinosis  of  varying  size,  dark  red 
in  color,  very  much  like  what  we  commonly  know  as  blood  blister, 
excepting  that  they  were  only  slightly  elevated  above  the  surrounding 
gum  tissue,  appeared  at  the  points  not  connected  with  the  erupting  or 
erupted  teeth.  ^  I  mention  this  point  because  nearly  all  wTiters  state 
that  the  sponginess  and  A'ascularity  of  the  giun  tissue  occurs  only  in 
connection  with  teeth,  and  is  not  seen  in  edentulous  mouths. 

"This  patient  was  given  local  treatment,  similar  in  therapeutic 
principle  to  the  former  one.  I  suggested  to  the  mother  to  give  the 
child  orange  juice  in  liberal  quantities.  The  family  physician,  Dr. 
John  H.  :\Iusser,  added  to  this  the  direction  to  give  the  child  the  pulp 
of  sound,  ripe  white  grapes.  In  addition  to  this,  beef  juice,  rare  meat 
shredded,  milk,  potato,  etc.  The  change  was  rapid  and  wonderful. 
The  mouth  trouble  subsided  quickly,  and  the  whole  systemic  condition 
became  normal.  The  child  had  been  fed  ahnost  exclusively  on  pro- 
prietary foods. ''^ 

Other  Cases. — INIorse^  divides  the  symptoms  of  his  cases  into  three 
groups:  "One  was  characterized  by  tenderness  noticeable  when  the 
child  was  handled,  and  especially  on  the  legs,  and  it  gradually  increased 
until  the  child  ceased  to  use  its  legs.  The  thigh  was  flexed  on  the 
abdomen  and  the  leg  on  the  thigh.  The  natural  mistake  was  to  regard 
this  as  rhemnatism  or  paralysis.  The  gums  swelled  sometimes  before 
the  appearance  of  the  teeth,  sometimes  after  eruption.  In  some 
instances  hematuria  persisted  for  weeks  or  months  and  led  to  the 
diagnosis  of  acute  nephritis,  tumor  of  the  bladder,  uric  acid  diathesis, 
etc.  Unless  treatment  was  given  there  appeared  swellings  in  the 
extremities  due  to  subperiosteal  hemorrhages  in  the  diathesis.  These 
occurred  most  frequently  in  the  lower  portion  of  the  femur,  less  often 
in  the  upper  part  of  the  tibia,  and  still  less  often  in  the  lower  part  of 
the  humerus.  ^  Such  severe  cases  were  mistaken  for  osteomyelitis  and 
acute  superficial  edema." 

Interesting  cases  have  also  been  reported  by  Irving  Snow^  and 
Coots.-*  George  Dock^  reports  a  case  of  infantile  scurvy  which  for 
two  months  had  been  treated  as  neuritis  and  anterior  poliomyelitis. 
"The  child,  aged  two  months,  was  admitted  to  the  hospital  October 
23,  1904.  The  mother  had  been  able  to  nurse  her  for  only  three  weeks, 
and  then  gave  her  equal  parts  of  milk  and  water,  sterilized  by  boiling 

'  From  the  Dental  Cosmos,  June,  1895.  2  Med.  Rec,  October  19,  1908. 

3  Arch.  Pediat.,  August,  1905. 

*  St.  Louis  Med.  Review,  March  24,  1907. 

6  Jour.  Am.  Med.  Assn.,  January  27,  1906;  Practical  Medicine  Series,  1908,  vii. 


PURPURA  189 

for  one  hour.  After  that  barley  gruel  and  milk-sugar  were  added  to 
the  milk,  and  later  a  preparation  of  Mellin's  Food,  which  had  been 
heated  about  ten  minutes  was  tried. 

"Toward  the  end  of  August  the  stools  contained  bright  red  blood 
and  then  for  two  or  three  weeks  they  were  almost  black.  The  baby 
screamed  when  her  feet  and  back  were  touched,  and  soon  ceased  to 
use  her  legs  or  arms  or  to  sit  up;  the  upper  gum  swelled  and  looked 
like  a  blood  blister,  and  then  the  lower  one  did  the  same  thing.  A 
little  later  the  upper  right  eyelid  suddenly  swelled,  but  the  swelling 
subsided  a  bluish- red  discoloration,  then  the  left  upper  eyelid  became 
involved. 

"The  baby  now  weighs  fifteen  pounds.  Both  eyes  are  prominent 
and  seem  to  look  do^vn.  The  upper  eyelids  are  slightly  swollen,  and 
the  right  shows  a  pale  blue  oval  discoloration  at  the  upper  margin. 
The  gum  around  the  lower  central  incisors  is  slightly  swollen,  reddish 
purple,  especially  close  to  the  teeth.  The  upper  incisors  cannot  be 
seen,  the  gmii  over  them  is  so  swollen  and  ulcerated.  The  left  arm 
lies  extended,  the  right  thumb  is  in  the  mouth  and  cannot  be  moved 
without  causing  pain.  The  ^Tists  and  lower  fourths  of  the  forearms 
are  swollen;  there  is  a  firm  swelling  apparently  beneath  the  deeper 
fascia.  The  legs  and  feet  are  extended  and  no  effort  is  made  to  move 
them.  The  lower  thirds  of  the  legs  and  ankles  are  swollen;  the  swelling 
is  firm  and  the  skin  over  it  glossy,  bluish  yellow,  and  pitted  like  orange 
peel.    When  the  arms  are  touched  the  child  cries. 

"Orange  juice  and  a  cream  and  milk  mixture  were  given  as  soon  as 
the  baby  was  admitted  to  the  hospital  and  later  mutton  broth 
cooked  with  potato  and  carrot.  Improvement  was  inomediately 
noted." 

Diagnosis. — Infantile  scurvy  is  differentiated  from  rheumatism 
because  the  latter  affection  never  occurs  at  this  early  age,  and  the 
swellings  are  over  the  joints  and  not  over  the  epiphysis.  Rheumatism 
is  never  accompanied  by  bleeding  gums  or  hematuria.  It  is  distin- 
guished from  periostitis  and  osteomyelitis,  because  in  those  affections 
the  tenderness  and  swelling  are  limited  in  extent  and  accompanied 
by  signs  of  acute  inflammation,  also  because  of  its  bleeding  gums ;  from 
infantile  paralysis,  because  of  the  sudden  onset  of  that  affection;  from 
difficult  dentition,  by  difterence  in  the  appearance  of  the  gums;  from 
traumatism  and  hip  disease,  because  of  the  general  symptoms  that 
accompany  scurv^^  The  final  test,  however,  is  the  improvement  of 
the  patient  upon  administration  of  orange  or  lemon  juice  and  other 
changes  in  diet. 

Prognosis. — ^The  prognosis  is  good  if  the  disease  is  recognized  early 
and  corrective  measures  are  temporarily  instituted. 

Treatment. — As  already  indicated,  orange  or  lemon  juice,  about  two 
tablespoonfuls  daily,  fresh  beef  juice  in  such  quantities  as  may  be 
administered  without  disturbance  of  the  child's  digestion,  plenty  of 
fresh  air  and  good  general  care  with  careful  readjustment  of  the  food 


190  DISEASES  OF  MUCOUS  MEMBRANE  OF  MOUTH 

formula.  Soothing,  mildly  astringent,  antiseptic  mouth  washes  are 
required  for  the  treatment  of  the  mouth  and  gums.  Immobilization 
of  the  limbs  is  sometimes  necessary  to  relieve  pain  and  tenderness. 

BLASTOMYCOSIS  CUTIS. 

Blastomycosis  is  a  chronic  infectious  inflammatory  disease  caused 
by  a  pathogenic  fungus. 

Etiology. — Blastomycetes  gain  entrance  to  the  tissues  often  through 
some  external  wound.  When  these  have  a  pathogenic  tendency,  their 
budding  leads  to  the  formation  of  miliary  abscesses  which  frequently 
require  microscopic  and  cultural  examination  to  differentiate  from 
tuberculosis. 

Symptoms. — The  papule  A\hich  marks  the  beginning  of  the  disease 
becomes  covered  with  crust,  enlarges,  and  assumes  a  warty  appearance. 
The  papules  enlarge  until  they  sometimes  cover  quite  considerable 
surfaces  which  are  elevated,  have  sharply  defined  borders,  and  as  they 
become  older  lose  the  appearance  of  dryness  and  become  more  or  less 
softened  with  pus  at  the  base.  The  skin  surrounding  these  is  filled 
with  tiny  abscesses,  so  small  as  to  be  barely  visible  to  the  naked  eye. 
The  pus  that  exudes  when  they  are  punctured  contains  the  A^east 
organism.  It  quite  frequently  affects  the  face,  and  may  therefore  be 
found  upon  the  lips.    Its  resemblance  to  syphilis  is  often  marked. 

Prognosis. — Its  chief  danger  of  fatal  termination  lies  in  the  develop- 
ment of  pyemia  or  some  form  of  septicemic  complication. 

Treatment. — The  treatment  consists  in  excision,  the  application  of 
.T-rays,  administration  of  large  doses  of  potassium  iodide,  and  copper 
sulphate  applied  locally. 

ERYSIPELAS. 

Erysipelas  is  an  acute  specific  inflammation  of  the  skin  and  sub- 
cutaneous tissues  characterized  by  pronounced  general  symptoms. 

Etiology. — Its  cause  is  generally  admitted  to  be  the  Streptococcus 
erysipelatis  of  Fehleisen,  although  other  organisms  are  often  present. 
Wounds  and  even  slight  abrasions  or  imperfections  in  the  skin  and 
mucous  membrane  surfaces  give  opportunity  for  entrance  of  the  germs. 
Uncleanliness,  alcoholism,  general  debility,  diseases  of  the  kidney  and 
of  other  vital  organs  may  be  predisposing  causes. 

Symptoms.^Its  symptoms  are  usually  ushered  in  by  a  distinct  chill 
followed  by  fever  (usually  103°  or  104°  F.),  headache,  and  sometimes 
nausea.  The  degree  of  fever,  as  with  other  infections,  is  usuall  ayn 
indication  of  the  character  of  the  disease.  Its  first  apj)earance  is 
usually  in  the  neighborhood  of  the  infection.  Otherwise  the  muco- 
cutaneous junctions,  such  as  the  nostrils,  angles  of  the  mouth,  eyelids, 
and  ear,  are  the  points  of  onset.  It  begins  with  a  rose-red  spot,  which 
spreads  peripherally  and  sometimes  very  rapidly  until  considerable 
surfaces  may  be  covered,  when  the  blush-like  appearance  may  change 
to  various  hues  of  yellow,  brown,  or  darker  shades. 


ERYSIPELAS  191 

The  skin  surface  is  hot,  tender,  and  glazed,  with  tendency  to  become 
indurated  and  rough  to  the  touch.  The  swelUng  may  be  shght,  or  if 
in  the  neigli})orhood  of  the  eyehds  or  other  loose  skin  surfaces,  is  some- 
times a  ^'ery  marked  symi)tom.  As  the  disease  progresses,  there  usually 
is  formation  of  ^'esicles  and  blebs  ^^■hich  may  be  filled  with  clear  scrum, 
be  purulent  or  in  severe  cases  hemorrhagic.  The  lymphatic  ganglia 
sometimes  show  marked  effect  of  infection.  The  subjective  symptoms 
are  burning,  itching,  local  tension,  and  tenderness  to  pressure.  Usually 
such  attacks  run  their  course  in  less  than  two  weeks,  but  unfavorable 
conditions  may  cause  their  prolongation  for  a  much  longer  period. 

A  form  of  this  disease  which  disappears  from  one  region  of  the  body 
and  reappears  in  another  is  called  erysipelas  migrans  or  amhidans. 

Mucous  Membrane  Svrfaces. — Although  chiefly  affecting  the  skin 
surface,  erysipelas  may  spread  to  the  mucous  membrane  surfaces  of  the 
nose,  pharynx,  throat,  and  other  parts.  When  the  pharynx  is  affected 
there  is  usually  marked  swelling  of  the  submaxillary  and  cervical 
glands,  a  burning  sensation  in  the  throat,  accompanied  by  intense 
dryness  and  difficult  breathing.  Edema  in  these  cases  is  a  serious 
complication.  Marshall^  reports  a  patient  dying  from  suffocation  in 
this  condition  when  associated  with  dento-alveolar  abscess.  The 
mucous  membrane  of  the  mouth,  as  \Aell  as  the  throat,  assumes  a  dark 
red  color,  vesicles  appear  upon  its  surface  with  general  swelling.  Glos- 
sitis is  frequently  a  marked  symptom.  Enjsij^eJas  neonatorum  is  a  form 
of  the  disease  affecting  newly  born  children.  It  is  quite  commonly 
fatal  and  undoubtedly  due  to  infection.  Its  first  manifestations  appear 
in  the  region  of  the  umbilical  cord.  The  symptoms  are  marked,  pro- 
gress rapidly,  and  usually  terminate  in  collapse  and  death  in  the  course 
of  a  few  days. 

Diagnosis.^ — Facial  erysipelas  is  distinguished  from  erythematous 
eczema,  although  in  the  latter  there  may  be  great  swelling  and  closure 
of  the  eyes,  by  the  absence  of  fever  and  constitutional  symptoms.  In 
erysipelas  the  border  is  more  sharply  defined. 

Prognosis. — The  prognosis  is  good  unless  abscesses  or  gangrene 
develop,  or  when  age,  habits  of  life,  or  constitutional  conditions  are 
unfavorable.    In  such  cases  there  may  be  fatal  termination. 

Treatment. — Remove  predisposing  condition  by  disinfection  of  wound 
surfaces  and  building  up  the  general  health.  Give  light,  easily  assimi- 
lated, nourishing  diet. 

Local  application  of  ichthyol  ointment,  such  as — 

I^ — Ichthyol 5j-ij 

Lanolin, 

Adipis  benzoat aa     5iv 

Sig. — Applj^  to  affected  surface.      (.Schamberg.) 

or  lead  water  and  laudanum  may  be  grateful  in  relief  of  local  irritations.. 
Local  applications  of  a  hot  saturated  solution  of  magnesium  sulphate 
are  of  decided  "s^alue. 

1  Surgery  of  the  Face,  Mouth  and  Jaws,  p.  127. 


CHAPTER  V. 

DISEASES  OF  THE  NERVOUS  SYSTEM  AFFECTING 
THE  BUCCAL  REGION. 

Because  of  the  wide  distribution  of  such  affections  it  is  difficult  to 
take  up  the  consideration  of  all  nervous  diseases  that  may  be  directly 
or  indirectly  manifested  in  this  field,  but  it  is  essential  that  at  least  a 
measure  of  consideration  be  given  to  neuroses  which  through  direct 
connection  with  the  parts  in  this  anatomical  situation,  or  because  of 
oral  symptoms  that  may  be  of  diagnostic  value,  should  be  understood 
by  those  whose  practice  favors  their  observation  during  early  stages, 
even  though  the  actual  seat  of  the  disease  may  be  in  some  other  division 
of  the  body. 

Injuries  of  Nerves.^ — Nerves  are  frequently  injured,  being  exposed 
in  their  long  course.  The  pathological  effects  of  such  injury  and  the 
symptoms  produced  are  somewhat  difl^erent  from  those  of  neuritis, 
hence  they  require  a  separate  consideration. 

Present  knowledge  is  chiefly  based  upon  experimental  division  of 
nerves  in  animals,  but  notwithstanding  controversial  opinion,  it  is 
assumed  that  the  process  in  man  is  much  the  same  as  in  animals. 

The  cut  end  of  a  divided  nerve  becomes  swollen  into  a  bulbar 
extremity  by  growth  of  connective  tissue  and  by  the  development  of 
fine  nerve  fibers  in  process  of  regeneration.  This  forms  a  very  sensitive 
scar.  Whether  a  true  union  of  the  divided  ends  ever  occurs  is  still  a 
matter  of  dispute. 

The  Process  of  Regeneration. — Ranvier  and  his  followers  affirm  that 
the  new  nerve  is  wholly  a  product  of  the  central  end  of  the  injured 
nerve,  growing  out  from  it  and  making  its  way  along  the  track  of  the 
peripheral  end,  which  takes  no  active  part  in  the  process.  This  rule 
has  recently  received  confirmation  by  the  studies  of  Harrison  and 
Mayer,  and  more  recently  Ballance  and  Stewart  have  affirmed  to  the 
contrary  that  the  regeneration  goes  on  in  the  peripheral  end  of  the 
cut  nerve,  segment  by  segment  being  formed  successively  or  simul- 
taneously, the  new  nerve  being  built  up  by  the  union  of  each  distal 
segment  with  one  lying  centrally  to  it,  until  the  process  is  complete. 
All  surgeons  believe  that  function  may  be  rapidly  resumed  after  suture 
of  freshly  divided  nerves  with  rapid  restoration  of  sensation. 

NEURITIS. 

Classification. — The  forms  of  neuritis  may  be  described  as :  Localized, 
when  the  nerve  is  inflamed  in  the  short  portion  of  its  course;  Dissemi- 
nated, when  affected  at  many  different  parts;  General,  when  diseased 

1  Starr,  Nervous  Diseases,  Organic  and  Functional,  Pai^t  II,  4th  ed.,  pp.  159  to  173. 
(192) 


NEURITIS  193 

in  its  entire  length;  Ascending  or  Descending,  according  to  the  direc- 
tion in  which  disease  makes  progress,  and  Migratory,  with  tendency 
to  appear  in  different  parts  of  nerve  distribution. 

Multiple  neuritis,  jjolyneuritis,  or  yeripheral  neuritis  is  a  general 
disseminated  inflammation  upon  both  sides  of  the  body  and  generally 
affecting  all  the  nerves  of  the  limbs,  particularly  in  their  terminal 
branches.  The  affection  rarely,  if  ever,  extends  as  high  as  the  nerve 
plexuses. 

Etiology.— Neuritis  may  occur  secondarily  to  inflammatory  changes 
in  other  parts,  as  with  periostitis  or  abscesses.  S^-philitic  deposits  in 
the  nerves,  tubercles  in  the  nerves,  cancer  or  other  neoplasms  along 
the  nerves,  may  cause  a  proliferation  of  the  connective-tissue  elements 
or  a  true  diffuse  inflammation. 

It  may  result  from  traiunatic  or  other  injury  to  the  nerve.  Among 
other  underlying  causes  are  constitutional  diseases,  blood  disorders, 
inflammatory  changes  in  other  parts,  as  from  periostitis,  abscess,  etc., 
septic  infection,  auto-intoxication,  and  other  toxic  effects,  from  lead, 
alcohol,  and  other  poisons. 

Midtiple  neuritis  is  due  to  general  constitutional  states.  La  grippe 
is  a  frequent  cause.  It  is  more  common  in  males  than  in  females,  and 
may  affect  all  ages.  The  diphtheritic  type  is  more  commonly  seen  in 
children.  Heredity  appears  to  play  little  or  no  part  in  the  causation, 
excepting  insofar  as  the  general  tendencies  to  gout,  rheumatism, 
diabetes,  carcinoma,  arterial  sclerosis  and  tuberculosis  may  be  said  to 
be  hereditary. 

Pathology. — An  inflamed  nerve  is  red  and  sw^ollen,  lacking  in  its 
natural  surface  luster,  and  no  longer  firm  and  smooth  to  the  touch. 
Its  vessels  are  congested,  and  there  may  be  hemorrhage  within  its 
sheath.  If  the  process  has  been  in  progress  for  some  time  there  may  be 
bulbous  swellings  on  the  nerve  resulting  from  connective-tissue  infil- 
tration, or  the  nerve  may  be  markedly  atrophied.  A  section  of  the 
nerve  as  viewed  by  the  microscope  shows  a  distention  of  the  vessels, 
an  infiltration  of  the  endoneurium  with  small  cells,  and  a  thickening 
of  the  connective-tissue  elements.  Pathological  distinctions  are  marked 
by  the  following  forms  of  the  disease. 

Parenchymatous  Neuritis. — At  the  outset  the  myelin  sheath  appears 
slightly  swollen  or  else  homogeneous,  and  from  a  difference  of  refractive 
power  is  less  translucent. 

Interstitial  Neuritis. — Interstitial  neuritis  shows  the  nerve  to  be  con- 
gested, swollen,  thicker  than  normal,  and  lacking  in  luster,  or  to  be 
yellow  and  irregular  and  swollen  by  the  accumulation  of  pus  and 
serum  and  reduced  to  a  nerve  connective-tissue  strand. 

Segmental  Periaxillary  Neuritis. — A  toxic  neuritis  from  lead  or 
alcohol  poisoning  in  which  the  degenerative  process  is  not  uniform 
throughout  the  entire  length  of  the  nerve  fiber. 

Symptoms. — The  sjTnptoms  of  neuritis  are  pain  and  tenderness 
along  the  course  of  the  nerve.  The  latter  is  its  distinguishing  feature. 
13 


194  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Severe  attacks  of  neuralgia  accompany  or  follow  la  grippe  in  about 
15  per  cent,  of  the  cases,  and  are  an  evidence  of  direct  action  of  the 
poison  upon  the  nerve  trunks.  Thus  trigeminal  neuralgia,  occipital 
neuralgia,  intercostal  neuralgia,  and  sciatica  frequently  develop  and 
some  run  a  very  severe  and  long  course.  They  are  occasionally  bilateral 
and  symmetrical,  which  is  rare  under  other  conditions. 

Many  cases  of  local  neuritis  appearing  simultaneously  in  one  or  in 
several  nerves  in  the  body  have  been  observed  after  la  grippe.  Any 
of  the  cranial  or  spinal  nerves  may  be  involved. 

Prognosis.^ — The  prognosis  in  neuritis,  as  a  rule,  is  good.  There  is  a 
spontaneous  tendency  to  regeneration  in  a  nerve  that  is  injured  or  that 
has  been  affected  by  inflammation,  and  while  this  progress  toward 
recovery  is  usually  slow,  yet  eventually  it  becomes  complete  and  all 
functions  of  the  nerve  are  restored.  Recovery  is  impossible  if  a  union 
between  the  several  ends  of  the  nerve  is  prevented  by  the  interposition 
of  a  callus,  or  intervening  connective-tissue  scar;  but  after  such  obstruc- 
tions are  remedied  by  surgical  treatment,  regeneration  takes  place, 
even  though  the  obstruction  may  have  persisted  for  many  months. 
Spontaneous  recovery,  unless  the  ner\'e  is  put  in  normal  condition  by 
being  freed  from  scar  tissue,  many  not  occur. 

Bruns^  has  called  attention  to  the  ultimate  results  in  injuries  of 
the  nerves  and  of  the  plexuses,  and  has  shown  that  while  two-thirds 
of  his  cases  of  nerve  injury  recovered,  only  about  one-quarter  of  the 
cases  of  injuries  of  the  plexuses  were  cured. ^ 

Treatment. — In  the  treatment  of  injuries  and  wounds  of  nerves  or 
in  spontaneous  neuritis  the  first  and  most  important  object  is  to  secure 
the  possibility  of  regeneration  by  establishing  the  continuity  of  the 
injured  nerve.  Clean-cut  ends  of  the  ner^•e  may  be  brought  together 
and  carefully  united,  as  in  Fig.  96,  or  if  laceration  has  taken  place 
with  loss  of  continuity,  a  flap  may  be  made  from  both  ends  and  these 
elongated  nerves  then  united  (Fig.  97).  Inserting  the  ends  within  a 
tube  of  decalcified  bone  or  a  non-absorbable  celloidin  tube  as  advocated 
by  Sweet,  may  serve  to  direct  the  regenerating  fibers  outward  toward 
the  distal  end  and  prevent  the  regenerating  nerve  from  becoming 
entangled  in  an  obstructing  mass  of  connective  tissue.  Ochsner  has 
secured  good  results  with  catgut  extensions  to  promote  union,  even 
when  a  distance  of  half  an  inch  or  more  was  to  be  bridged. 

In  cases  of  spontaneous  neuritis  from  cold,  etc.,  it  is  only  necessary 
to  maintain  the  parts  in  a  perfectly  quiet  position,  and,  if  possible,  to 
reduce  congestion  in  the  inflamed  nerve.  This  may  be  done  by  the  use 
of  a  counter-irritant,  of  which  the  actual  cautery  is  probably  the  best. 
Light  touching  with  a  Pac|uelin  cautery  along  the  course  of  the  inflamed 
nerve  will  often  relieve  intense  pain  and  reduce  the  congestion  which 
attends  spontaneous  neuritis.  Small  mustard  plasters  are  also  of  service. 

', Starr:  Nervous  Diseases,  Organic  and  Functional,  4th  ed.,  i).  178. 

2j'Neurol.  Cent.,  November,  1902. 

3  Kennedy:  British  Med.  Jour.,  February  7,  1903. 


TUMORS  OF  THE  NERVES 


195 


Local  .applications  of  heat  are  often  very  grateful  in  painful  condi- 
tions of  nevu'itis,  and  usually  more  agreeable  than  cold;  poultices  or 
packing  the  affected  limb  in  cotton-wool  covered  with  oiled  silk  may 


Fig.  96. — Methods  of  nerve  suturing:  A,  B,  sutures  passing  through  sheath  and  part 
of  nerve;  C,  sutures  through  sheath,  reinforced  by  relaxation  suture  through  entire  nerve. 
(After  Brewer.) 

be  of  ser^•ice.  In  more  severe  cases,  with  intense  pain  which  prevents 
rest  at  night,  it  may  be  necessary  to  use  analgesics.  Antipyrine,  10 
grains;  acetanilid,  3  grains;  exalgin,  3  grains;  or  salophen,  10  grains. 


Fig.  97. — Nerve  suturing,  with  lengthening.      (After  Brewer.) 

may  be  used  every  two  or  three  hours ;  or  a  combination  of  these  with  a 
small  amount  of  codein  if  the  pain  is  very  persistent.  The  following 
formula  is  generally  used : 

I^ — Phenacetin ^t.  vj 

Acetanilid gr.  iij 

Codein gr.  | 

Caffein gr.  ij 

Sacch.  lactis gr.  v 

Mix  and  triturate. 

Sig. — One  such  powder  every  three  hours. 


TUMORS  OF  THE  NERVES. 

Neuroma. — Any  form  of  tmnor  (fibroma,  angioma,  sarcoma,  etc.) 
may  develop  within  a  nerve  sheath  or  upon  it  and  thus  produce  an 
apparent  tumor  of  the  nerve.  In  such  cases  the  nerve  fibers  may  pass 
through  the  tumor  or  may  be  dissected  apart  by  it  and  pass  around  it. 
Such  tumors  have  been  termed  false  neuromata,  for  they  are  not 
composed  of  nerve  cells  or  fibers.    But  the  fibers  may  become  com- 


196  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

pressed  by  the  newgrowth  and  undergo  degeneration.  The  symptoms 
and  course  of  the  case  under  such  conditions  will  be  expressed  according 
to  the  character  of  the  affected  nerve. 

Starr^  gives  the  following  description : 

"Neuromata,  or  tumors  consisting  of  nerve  fibers,  first  described 
by  Virchow,  are  a  rare  form  of  tumor.  The  fibel-s  of  which  they  con- 
sist may  be  medullated  or  non-medullated ;  nerve  cells  are  not  found 
in  such  tumors;  connective  tissue  exists  in  greater  or  lesser  degree,  so 
that  some  tumors  are  neurofibromata.  There  appears  to  be  a  tendency 
for  such  tumors  to  be  multiple,  and  in  the  large  majority  of  recorded 
cases  hundreds  of  minute  tumors  have  developed.  Occasionally  the 
tumors  have  been  large,  but  usually  they  are  the  size  of  a  pea.  When 
they  appear  on  the  sensory  nerves  of  the  skin  they  are  easily  felt  and 
are  usually  tender.  Under  these  circumstances  they  have  been  called 
'  tubercula  dolorosa.'  I  have  seen  a  patient  with  more  than  a  hundred 
such  tumors  distributed  over  the  entire  body.  Hoggan  has  shown  that 
some  tumors  of  this  description  were  adenomata  of  the  sweat  glands. 
That  some  congenital  tendency  to  the  multiplication  of  nerve  fibers 
is  at  the  basis  of  this  affection  is  proved  by  the  fact  that  many  of  the 
cases  reported  have  been  in  children.  Thus  in  the  so-called  plexiform 
neuroma  of  the  fifth  nerve  the  disease  is  usually  congenital  and  other 
nerves  have  been  affected  later  in  life.  The  tumors  obtain  a  certain 
size,  and  then,  as  a  rule,  cease  to  grow;  the  condition  remains  permanent 
until  death  from  some  other  cause. 

"In  the  majority  of  cases  no  sjonptoms  are  caused  by  neuromata, 
as  the  nerves  on  which  the  tumors  develop  are  not  afPected  by  the 
growth.  The  tumors  may  be  felt  and  may  be  tender  to  pressure.  They 
are  not  subject  to  treatment  and  cannot  safely  be  removed,  as  they  are 
so  numerous,  and  as  the  nerves  may  be  cut.  Occasionally  pain,  hyper- 
esthesia, and  numbness  are  caused  by  neuromata. 

"There  is  one  form  of  neuroma  which,  however,  requires  special 
mention.  It  is  the  neuroma  which  develops  on  the  cut  end  of  a  divided 
nerve,  either  after  an  amputation  or  after  an  injiu-y  without  union. 
Such  a  neuroma  may  be  extremely  painful  to  the  peripheral  termination 
of  the  nerve,  and  also  cause  spasms  in  the  muscles  related  to  these 
terminations.  In  such  cases  excision  is  imperative,  but  recurrence  is 
not  infrequent. 

"  In  one  patient  under  my  observation  who  suffered  from  great  pain 
referred  to  the  toes  for  many  years  after  an  amputation  of  the  leg 
above  the  knee,  excision  of  the  neuroma  on  the  sciatic  failed  to  give 
relief.  A  portion  of  the  sciatic  nerve  in  the  thigh  was  then  excised, 
but  this  also  failed  to  stop  the  pain.  In  this  case  it  seemed  probable 
that  atrophic  changes  had  occurred  in  the  spinal  cord,  such  as  are 
known  to  follow  amputations,  and  that  these  had  involved  not  only  the 
anterior  horns,  but  also  the  sensory  columns." 

1  Nervous  Diseases,  Organic  and  Functional,  4th  ed.,  p.  193. 


DISEASES  OF  THE  SPINAL  CORD  197 

DISEASES    OF  THE    SPINAL   CORD,  ETIOLOGICALLY,   SYMP- 

TOMATICALLY,  OR  OTHERWISE  RELATED  TO  THE 

REGION  OF  THE  MOUTH,  FACE  AND  JAWS. 

The  following  diseases  deserve  the  special  consideration  of  all  who 
undertake  the  treatment  of  buccal  affections,  because  (1)  the  face  and 
mouth  so  frequently  evidence  developmental  imperfections  which  are 
indicative  of  neurotic  tendencies  that  predispose  to  spinal  diseases. 
(2)  Direct  and  reflex  irritations  from  developing  teeth  and  other  causes 
sometimes  give  rise  to  disturbance  through  trigeminal  irritation,  which 
may  increase  susceptibility  to  other  nerve  affections.  (3)  In  many 
of  the  spinal  diseases  the  etiological  character  of  which  is  not  fully 
understood,  it  wdll  be  noted  that  infection  and  disturbance  of  the  diges- 
tive tract  are  among  the  constantly  recognized  important  factors, 
therefore  the  causal  relation  of  pyogenic  microorganisms  of  the  mouth 
and  diseased  conditions  directly  or  indirectly  connected  therewith, 
including  malnutrition,  must  receive  due  consideration.  (4)  Symp- 
toms affecting  the  facial,  buccal,  and  lingual  regions  are  of  vital  interest 
because  they  indicate  the  upward  progression  of  spinal  diseases  that 
by  giving  rise  to  bulbar  paralysis  point  the  way  to  hopeless  prognosis, 
without  due  recognition  of  which  the  true  disease  might  be  confused 
with  affections  of  the  cranial  nerves  or  brain  of  vastly  different  char- 
acter. (5)  There  is  a  significant  developmental  relation  between 
atrophic  and  hypertrophic  tendencies  commonly  associated  with 
spinal  affections  and  deformities,  as  noted  in  the  teeth,  palate,  jaws, 
and  bones  of  the  face,  that  deserves  much  greater  attention  than  it 
has  yet  received  with  reference  to  both  diagnosis  and  treatment  of  oral 
and  facial  deformities. 

Syringomyelia  or  Glossis  Spinalis.— This  is  a  central  myehtis  and 
is  marked  by  the  formation  in  the  spinal  cord  of  a  fissine  or  canal 
which  is  usually  posterior  to  the  central  canal  and  preceded  by  hj-per- 
plasia,  degeneration,  and  softening  of  the  neuroglia. 

Etiology. — Without  exact  knowledge  of  a  true  cause,  the  cormnonly 
accepted  factors  pertaining  to  the  etiology  of  this  afl'ection  are  based 
chiefly  upon  pathological  manifestations.  These  indicate  that  it  may 
be  due  (a)  to  congenital  defects  of  development,  (b)  disintegration  of 
the  spinal  cord  from  inflammatory  causes,  (c)  retrograde  metamor- 
phosis caused  by  impairment  of  tissue  nutrition  by  obstruction  to  the 
circulation,  (d)  destruction  of  the  cord  by  hemorrhage. 

Bacterial  infection  is  quite  generally  recognized  as  an  important 
etiological  factor. 

Symptoms. — Analgesia. — There  is  a  loss  of  the  sensation  of  pain  and 
temperature  with  preservation  of  the  tactile  sense  in  the  analgesic 
area.  The  affected  part  of  the  body  will  necessarily  depend  upon  the 
extent  of  the  lesion  of  the  cord.  Usually  the  hands  are  first  affected 
because  the  cervical  portion  of  the  cord  is  most  commonly  the  point 
of  origin.    By  reason  of  the  fact  that  the  sense  of  touch  is  seldom 


198  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

influenced,  patients  are  frequently  unconscious  of  the  anesthetic 
condition  of  the  affected  parts  until  it  is  demonstrated  that  there  is 
no  pain  felt  from  pricking,  cutting  or  burning.  Sometimes  the  sensa- 
tion of  cold  is  recognized  and  that  of  heat  much  impaired,  or  vice  versa. 

Trophic  Disturbance. — Trophic  disturbances  occur  through  injury 
to  which  there  is  a  predisposition  on  account  of  the  insensibility  to 
pain  of  the  affected  area  of  the  body  and  because  of  the  impairment 
of  nutrition  through  affection  of  the  trophic  centers  of  the  spinal  cord. 
Abnormalities  of  the  skin  are  noted  in  these  cases,  varying  from  slight 
surface  changes,  to  ulcers,  gangrene,  and  graver  conditions  of  this 
character.  The  extremities  and  joints  are  also  frequently  affected, 
particularly  the  shoulder,  elbow,  and  wrist,  in  contradistinction  to 
tabes,  w^hich  more  often  affects  the  lower  extremities. 

Muscular  atrophy  attended  by  paralysis  affects  many  of  these  patients. 
Extension  of  the  disease  to  the  medulla  may  cause  any  of  the  cranial 
nerves  to  become  affected.  The  involvement  of  the  motor  portion  of 
the  fifth  and  glossopharyngeal  nerves,  as  in  syringobulbia  or  the  lower 
portion  of  the  nucleus  of  the  seventh  nerve,  sometimes  gives  rise  to 
intense  atrophy  of  the  tongue,  disturbance  of  speech,  facial  paralysis, 
and  other  symptoms  in  the  area  of  distribution  of  these  nerves. 

Diagnosis. — Recognition  of  the  tliree  characteristic  symptoms  of 
this  disease,  when  all  are  sufficiently  developed,  serves  to  distinguish 
it  from  other  affections  causing  bulbar  paralysis,  locomotor  ataxia, 
general  myelitis,  tumors  of  the  cord,  and  other  spinal  diseases. 

Treatment. — There  is  no  method  of  treatment  which  may  be  relied 
upon  to  check  the  progress  of  this  disease.  The  .T-rays,  radium,  elec- 
tricity, and  similar  measures  are  recommended.  Relief  of  symptoms 
is  about  all  that  can  be  done  with  benefit  in  a  therapeutic  or  surgical  way. 

Anterior  Poliomyelitis;  Acute  Anterior  Poliomyelitis;  Infantile 
Paralysis ;  Acute  Atrophic  Spinal  Paralysis,  or  Retrogressive  Paralysis. 
— Poliomyelitis  is  an  acute  disease  characterized  by  sudden,  complete 
loss  of  power  in  one  or  more  limbs,  usually  in  the  legs,  followed  by  rapid 
atrophy  of  the  paralyzed  muscles  and  imperfect  growth  of  the  limb, 
with  slight  pain  and  no  permanent  sensory  disorder.  It  occurs  chiefly 
among  children,  and  may  occasionally  affect  older  persons.  It  may  be 
of  sporadic  or  epidemic  form.  E.  Farquhar  Buzzard^  suggests  the  use 
of  the  term  acute  poliomyelitis  instead  of  acute  anterior  poliomyelitis, 
because  the  latter  term  is  misleading,  "  since  it  describes  the  limitation 
that  is  at  times  incorrect."  The  word  infantile  is  also  objected  to 
because  the  disease  is  within  any  of  the  first  four  decades  of  life. 

Etiology. — At  the  time  of  the  epidemic  appearance  of  poliomyelitis 
in  Norway  in  1903  to  1906,  F.  Harbitz  and  Osheel,  of  the  Pathological 
Institute  of  the  University  of  Christiania,  stated  that  it  seemed  to  be 
an  infectious  disease  with  living  virus,  possibly  diplococcus.  Epi- 
demics in  New  York  and  other  localities  in  1907  seemed  to  corroborate 

1  Practical  Medicine  Series,  1907,  x,  143;  Lancet,  March  16,  23,  and  30,  1907. 


DISEASES  OF  THE  SPINAL  CORD  199 

this  conclusion.  It  has  long  been  known,  as  stated  by  Buzzard,  that 
"  its  essential  lesion  is  an  inflammation  of  the  interstitial  tissue  of  the 
central  nervous  system  due  to  tlie  ])resence  of  microorganisms  or  other 
toxins,  probably  in  the  blood  (but  possibly  in  the  lymph)  circulating 
within  the  system." 

In  1910  the  United  States  Public  Health  and  Marine  Hospital 
Service  Report  stated  that  it  had  been  proved  "by  work  at  various 
laboratories,  notably  the  Rockefeller  Institute  for  Medical  Research, 
that  anterior  poliomyelitis  is  transmissible  to  monkeys;  that  the  causa- 
tive organism  is  a  'filterable  virus;'  that  not  only  the  central  nervous 
system,  but  also  the  secretions  of  the  nose  and  mouth  are  infective, 
and  that  the  most  probable  avenues  of  infection  are  the  respiratory 
and  digestive  tracts.  A  distinct  immunity  has  been  demonstrated  in 
recovered  animals,  holding  out  the  hope,  as  yet  far  from  realization, 
of  a  possible  specific  therapy."^ 

In  1913  Flexner  and  Xoguchi  reported  the  finding  of  a  microorganism 
which  they  described^  under  the  term  globoid  bodies.  During  the 
epidemic  of  1916  in  the  United  States,  George  Mathers  and  Ruth 
Tunnicliffe,  Xuzum  and  Herzog,  and  Rosenow,  Towne,  and  Wheeler, 
isolated  a  coccus,  which  according  to  their  researches  caused  experi- 
mental poliomyelitis.  Rosenow  and  Towne  hold  that  the  small  globoid 
microorganisms  which  Flexner  and  his  followers  believe  to  be  the  cause 
of  poliomyelitis  were,  as  a  matter  of  fact,  the  result  of  the  breaking 
down  of  large  diplococci  which  have  been  isolated  from  the  central 
nervous  tissues  of  each  monkey  affected  with  poliomyelitis. 

Simmons  sums  up  the  situation  by  stating  that  "the  fact  remains 
that  a  very  interesting  coccus  has  been  found  in  the  brain  and  spinal 
cord  of  patients  who  have  died  of  poliomyelitis,  but  its  relation  to  the 
disease  is  not  yet  determined." 

Symptoms. — Sporadic  Ca.5e.5.— Fever  may  rise  rapidly  to  102°  or 
103°  F.,  or  remain  at  about  101°  for  several  days  and  then  sink  to 
normal  in  the  course  of  about  six  or  seven  days.  There  may  be  convul- 
sions and  delirium,  vomiting,  diarrhea,  and  general  malaise,  with 
considerable  pain  in  the  back,  body,  and  limbs.  The  onset  of  the 
paralysis  may  be  sudden  or  appear  after  several  days.  Rigidity  of  the 
spine  and  neck  may  occur  as  in  meningitis.  When  the  other  symptoms 
subside  the  paralysis  remains.  The  paralyzed  muscles  undergo  atrophy 
with  marked  change  in  the  size  of  the  limb.  In  some  cases  the  febrile 
symptoms  do  not  appear,  the  paralysis  occurring  while  the  child  is 
apparently  in  good  health.  When  the  cranial  nerve  nuclei  are  invaded 
the  symptoms  which  ordinarily  appear  in  the  extremities  are  evidenced 
in  facial  palsy,  paralysis  of  the  larynx  and  tongue,  strabismus,  etc. 
Deformities  of  the  bones  and  joints  occur  as  sequelae  of  the  disease. 

Epidemic  Cases. — The  s\Tnptoms  in  this  form  of  acute  poliomyelitis 
are  similar  to  those  occurring  in  infectious  diseases.    There  is  an  initial 

1  Annual  Reports  United  States  Public  Health  and  Marine  Hospital  Service,  1910, 
p.  33. 


200  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

chill,  high  fever,  vomiting,  malaise,  severe  pains  in  the  back  and  limbS; 
with  occasional  rigidity  of  the  spine  and  retraction  of  the  head  as  in 
meningitis.  The  fever  usually  lasts  from  five  to  ten  days,  and  about 
the  third  or  fourth  day  the  paralysis  is  suddenly  manifested.  The 
paralysis  may  extend  to  the  neck,  throat,  face,  and  eyes,  and  present 
all  the  sjTnptoms  of  bulbar  palsy. 

Diagnosis. — There  is  usually  little  difficulty  in  recognizing  the  disease 
with  evidence  of  the  paralysis  and  history  of  the  initial  symptoms. 

Prognosis.- — The  prognosis  is  always  grave.  Death  sometimes  occurs 
durmg  the  acute  onset.  This  rarely  happens,  but  the  resulting  paralysis 
is  quite  permanent.  In  the  epidemic  cases  fatal  results  are  more  fre- 
quent and  usually  occur  from  paralysis  of  the  respiratory  muscles. 

Treatment. — In  the  acute  stage  the  child  must  be  kept  in  bed  and 
counter-irritation  should  be  applied  along  the  spine.  The  febrile  con- 
dition must  be  allayed  by  sponging  with  tepid  water  and  alcohol, 
light  nourishing  diet  is  required,  and  laxatives,  such  as  castor  oil,  are 
given  to  assist  elimination  of  gastro-intestinal  poisons  that  may  be 
present.  Ergot  in  10-minim  doses  of  the  fluidextract  for  a  child,  aged 
two  years,  is  recommended  to  be  given  every  four  hours,  with  2  minims 
more  for  each  additional  year.  Iodide  of  potassium,  1-grain  doses, 
salicylate  of  strontium  and  urotropin,  1  grain  every  six  hours  during 
the  first  ten  days,  are  all  recommended. 

The  intraspinal  injection  of  human  serum  from  recovered  and  con- 
valescent cases  of  the  disease  seems  to  offer  the  best  promise  of  success 
in  treatment. 

Amoss.  Chesney,  and  Draper^  report  and  recommend  its  use. 

Antipoliomyelitis  horse  serum  is  reported  to  have  protective  and 
curative  properties  against  the  virus  of  poliomyelitis.^ 

C.  W.  WeUs  recommends  the  intravenous  injections  of  immune 
serum  in  doses  of  50  to  100  c.c.  or  more  daily,  and  following  intra- 
venous or  intramuscular  injections  of  serum,  spinal  fluid  should  be 
withdrawn.  He  advocates  an  early  diagnosis  of  the  disease  and  an 
early  administration  of  the  serum. 

After  the  acute  symptoms  have  subsided  the  paralysis  and  atrophy 
require  such  treatment  as  massage,  hydrotherapy,  and  electricity,  and 
as  the  disease  progresses,  the  use  of  mechanical  appliances  for  support 
of  the  deformed  parts.  Operations  upon  the  muscles,  tendons,  and 
nerves,  especially  nerve  grafting,  give  promise  of  overcoming,  to  some 
extent  at  least,  the  effects  of  the  paral}'sis.  ]Much  progress  is  now 
being  made  in  the  direction  of  the  restoration  to  usefulness  of  children 
deformed  by  this  affliction. 

Neutralization  of  Virus  of  Poliomyelitis. — The  results  of  fifty- six  experi- 
ments by  Amoss  and  Taylor  showed  that  washings  of  the  nasal  and 
pharyngeal  mucosa  possess  definite  power  to  inactivate  or  neutralize 
the  active  virus  of  poUomyelitis.    This  power  is  not  absolutely  fixed, 

1  Jour.  Am.  Med.  Assn.,  May  12,  1917,  p.  1436. 

'  Neustaedter  and  Banzhaf:  Jour.  Am.  Med.  Assn.,  May  26,  1917,  p.  1531. 


DISEASES  OF  THE  SPINAL  CORD  201 

but  is  subject  to  fluctuation  in  a  given  person.  Apparently  inflam- 
matory conditions  of  the  upper  air  passages  tend  to  remove  or  diminish 
the  power  of  neutrahzation.  Mouth  disinfection  should  therefore  be 
recommended  in  all  growing  children  as  a  prophylactic  measure  and 
rigidly  maintained  during  the  treatment  of  such  cases. 

Chronic  Anterior  Poliomyelitis;  Chronic  Atrophic  Paralysis;  Pro- 
gressive Muscular  Atrophy. — This  is  a  condition  of  paralysis  with 
atrophy. 

Etiology. — The  etiological  factors  of  this  affection  appear  to  be  closely 
allied  to  those  already  enumerated  for  acute  anterior  poliomyelitis. 
Injury,  overwork,  exposure  to  cold,  and  infectious  diseases  are  the 
causes  most  frequently  reported.  Notwithstanding  this,  it  is  not  yet 
fully  established  whether  the  disease  is  inflammatory  or  degenerative 
in  character. 

Pathology.^ — ^There  is  a  slowly  advancing  atrophy  in  the  primary  motor 
neurons  of  the  cord,  the  cell  bodies,  dentrites,  and  axons  degenerating 
together.  These  cells  lie  in  groups  in  the  anterior  horns  and  the  central 
gray  matter,  and  the  lesion  afi'ects  these  groups  in  different  degrees. 

Symptoms. — The  sjinptoms  are  those  characteristic  of  aft'ections 
of  the  spinal  cord,  advancing  paralysis  affecting  one  leg,  then  the  other, 
the  feet,  hands,  etc.  In  the  last  stage,  as  the  disease  extends,  bulbar 
palsy  ensues  with  paralysis  and  atrophy.  The  muscles  of  the  face 
tongue,  and  throat  become  paralyzed  and  atrophied  with  difficulty  of 
speech,  swelling,  etc. 

Prognosis. — Death  usually  results  from  respiratory  or  bulbar  par- 
alysis and  the  prognosis  depends  upon  the  possibility  of  its  arrest 
before  these  symptoms  ensue.  Rapid  course  and  recurrence  are  both 
unfavorable. 

Treatment. — Good  hygienic  care  and  food,  moderate  exercise,  avoid- 
ance of  fatigue,  the  correction  of  any  associated  disease  or  etiological 
factor  that  may  exist.  Massage  and  electricity  are  sometimes  recom- 
mended, especially  mechanical  massage;  strychnin  and  similar  reme- 
dies are  occasionally  administered  to  advantage. 

Amyotrophic  Lateral  Sclerosis. — This  disease  is  a  chronic  progressive 
form  of  spinal  paralysis  characterized  by  the  symptoms  of  progressive 
muscular  atrophy.  It  was  formerly  believed  to  aftect  almost  exclu- 
sively the  arms  and  legs,  but  is  now  known  to  include  all  the  motor 
elements  of  the  nervous  system. 

Etiology. — ^The  causes  are  not  definitely  known.  Presumably  con- 
genital weakness  of  the  motor  elements  of  the  nervous  system  renders 
such  individuals  particularly  susceptible  to  cold,  overexertion,  various 
forms  of  poisoning,  such  as  alcohol,  arsenic,  lead,  mercury,  the  toxins 
of  infectious  diseases,  auto-intoxication,  rheumatism,  gout,  diabetes, 
etc. 

Symptoms. — Stiffness  of  the  muscles,  with  increased  reflex  excita- 
bility, followed  by  atrophy  and  paralysis  of  the  extremities,  is  some- 
times associated  with  bulbar  symptoms.    Occasionally  the  affection 


202  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

begins  with  bulbar  palsy,  and  in  these  cases  there  is  disturbance  of 
speech  due  to  paralysis  of  the  muscles  of  the  tongue,  lips,  mouth,  and 
palate.  Among  other  symptoms  are  fibrillary  twitchings  of  the  tongue, 
which  sometimes  protrudes  from  the  mouth,  difficulty  in  swallowing, 
attacks  of  choking,  with  return  of  fluids  through  the  nose  on  account 
of  paralysis  of  the  soft  palate,  paralysis  of  the  facial  muscles,  saliva 
flowing  from  the  corner  of  the  mouth,  etc.  There  is  increased  muscu- 
lar irritability,  so  that  percussion  of  the  masseter  and  other  muscles 
of  the  jaw  will  produce  a  sudden  spasmodic  contraction. 

Starr^  describes  the  following  case,  which  gives  a  goofl  clinical  picture 
of  the  disease.  "I.  D.,  aged  forty-two  years,  had  been  much  exposed 
to  wet,  to  extreme  heat,  and  to  cold  in  his  occupation,  and  had  suffered 
from  muscular  rheumatism  for  years.  In  February,  1889,  he  noticed 
double  vision,  due  to  a  lesion  of  the  left  external  rectus  muscle,  and  ptosis, 
which  first  affected  the  left  eye  and  then  the  right  eye.  The  ptosis 
gradually  subsided,  but  the  strabismus  remained.  In  March,  1889,  his 
speech  became  thick,  and  in  April  he  began  to  have  difficulty  in  swallow- 
ing, fluid  food  coming  out  of  his  nose.  In  May  he  noticed  difficulty  in 
chewing,  and  his  friends  saw  a  change  in  his  facial  expression  due  to  a 
weakness  of  the  facial  muscles.  During  all  this  time  he  felt  an  increas- 
ing weakness  in  all  his  movements.  His  neck  had  become  stiff  and 
his  head  tended  to  fall  forward  and  was  held  with  ch'n  projecting 
beyond  the  line  of  the  body.  On  several  occasions  after  March,  1889, 
he  had  fainting  attacks,  in  which  he  became  pulseless  and  pale.  In 
June,  when  I  saw  him,  he  was  thin  and  pale,  clear  in  his  mind,  but 
feeble  in  all  movements.  His  eyes  were  both  turned  in  a  little  and 
his  left  eye  looked  up.  He  had  corresponding  double  images,  but 
no  nystagmus,  and  his  pupils  were  normal.  His  optic  nerves  were 
normal,  but  the  muscles  of  mastication  were  atrophied,  did  not  react 
to  faradism,  and  were  so  weak  that  chewing  was  impossible.  He 
moved  his  jaw  with  his  hand  and  gave  it  constant  support.  His  face 
was  expressionless;  he  could  not  whistle,  food  collected  in  his  cheeks, 
but  all  his  facial  muscles  could  be  slightly  moved,  and  reacted  to 
faradism.  His  palate  was  paralyzed,  and  it  was  to  this  cause  that  his 
defect  of  speech  was  due,  as  the  tongue  was  not  paralyzed  or  atrophied. 
His  neck  muscles  were  weak.  There  was  an  atrophic  condition  of  the 
thenar  muscles  of  the  forearm.  The  deltoids  and  muscles  of  the  arms 
were  in  good  condition.  His  gait  was  slow  and  feeble,  but  not  spastic; 
but  his  knee-jerks  were  exaggerated  and  ankle-clonus  was  obtained. 
He  controlled  his  spincters  well.  During  the  following  year  his  par- 
alysis increased  in  his  arms  and  legs,  his  inability  to  talk  became  more 
apparent,  and  in  August,  1890,  he  choked  to  death." 

Diagnosis. — The  symptoms  in  some  respects  are  almost  self-evident, 
because  in  muscular  dystrophy  there  are  no  muscular  symptoms  or 
fibrillary  twitchings.     Bulbar  paralysis  alone  does  not  have  spinal 

'  Nervous  Diseases,  Organic  and  Functional,  4th  ed  ,  p.  300. 


DISEASES  OF  THE  SPINAL  CORD  203 

symptoms.  Absence  of  sensory  disturbances  or  trophic  affections 
distinguishes  it  from  syringomyeHa.  Tumors  of  the  spinal  cord  have 
sensory  sAinptoms  as  well  as  paralysis  and  muscular  atrophy,  as  does 
also  myelitis. 

The  effect  of  this  disease  upon  muscular  action  in  the  various  ana- 
tomical regions  is  quite  similar  to  that  of  progressive  muscular  atrophy. 
Although  positive  and  radical  lines  of  symptomatic  distinction  do  not 
seem  to  be  fully  warranted,  the  following  distinguishing  characteristics 
are  in  a  general  way  conclusive  according  to  some  writers,  notably 
Williamson  •} 

AMYOTROPHIC  LATERAL  PROGRESSIVE  MUSCULAR 

SCLEROSIS.  ATROPHY. 

1.  In     favor     of     amyotrophic     lateral  1.  These  symptoms  not  so  marked, 
sclerosis  would  be  a  spastic  condition  of 

the  legs,  spastic  gait,  scraping  of  the  toes 
in  walking,  rigidity  of  the  legs  on  passive 
movements,  increased  knee-jerks,  ankle- 
clonus,  and  the  extensive  tjTpe  of  plantar 
reflex,  Babinski's  reflex. 

2.  Symptoms  of  bulbar  paralysis  would  2.  These  symptoms  not  so  marked, 
be  in  favor  of  amyotrophic  lateral  sclerosis. 

3.  Runs  more  rapid  course.  Usually  3.  Tendency  to  become  chronic,  may 
terminates  fatally  in  from  one  to  four  continue  for  ten,  fifteen,  or  twenty  years, 
years. 

4.  Paresis  may  occur  without  muscular  4.  Muscular  atrophy  primary  symp- 
atrophy.                                                                         torn. 

Prognosis. — The  prognosis  is  exceedingly  doubtful.  Cases  of  recov- 
ery have  been  reported,  but  are  rare. 

Treatment. — Therapeutic  aid  must  rely  upon  efforts  to  build  up  the 
general  tone  of  the  system,  massage,  electricity,  good  hygienic  care, 
rest. 

Muscular  Dystrophies. — These  forms  of  paralysis  appear  in  early 
life,  and  are  regarded  as  due  to  muscular  and  not  nervous  disease. 

Etiology. — The  disease  is  recognized  as  one  of  development,  presum- 
ably an  inherent  tendency  toward  weakness  of  certain  muscles  indicating 
insufficient  developmental  vigor  in  these  parts,  or  the  trophic  influences 
to  which  they  are  subject.  ^lany  cases  have  been  reported  in  which 
the  family  history  showed  other  members  of  the  family  having  tendency 
to  muscular  dystrophy.  On  the  other  hand,  there  have  been  sufficient 
cases  in  which  no  hereditary  influence  could  be  recognized  to  eliminate 
it  as  a  constant  factor.  Occasionally  infectious  diseases,  unusual 
muscular  effort,  traumatism,  exposure  to  cold  and  similar  agents,  have 
appeared  to  be  influential. 

Symptoms. — The  symptoms  appear  in  early  life,  become  arrested 
in  the  course  of  its  progress  with  tendency  toward  improvement,  or  to 
continue  until  there  is  complete  muscular  destruction. 

The  different  forms  of  these  affections  bear  the  names  of  their  first 

1  Edinburgh  Med.  Jour.,  April,  1907. 


204  NERVOUS  SY^STEM  AXD  THE  BUCCAL  REGION 

observers,  as  Duchenne  type,  pseudoh\-pertrophy,  and  apparent  dis- 
proportionate increase  in  the  size  of  muscles  usually  beginning  with  the 
calves  of  the  legs,  which  is  rarely  an  increase  of  fat  cells  with  atrophy 
of  muscular  fibers.  The  Erb  type  of  juvenile  dystrophy,  usually 
beginning  between  the  ages  of  twelve  and  sixteen,  affecting  primarily 
the  muscles  of  the  shoulder,  which  become  h\-pertrophied  but  weak- 
ened, and  by  gradual  progress  affecting  the  muscles  of  the  body. 
Landmizy-Bejerine  dystrophy,  also  usually  developed  in  early  child- 
hood, but  occasionally  appears  in  adults.  Its  principal  feature  is 
muscular  atrophy  of  the  face,  which  begins  with  the  orbicularis  oris, 
extends  to  the  risorii,  to  the  levator  menti,  and  to  the  other  muscles 
of  the  face  associated  •^'ith  the  mouth.  In  consequence  the  lips  cannot 
be  firmly  closed,  the  mouth  i.^  liabitually  open  with  the  lips  projecting 
forward,  the  so-called  "tapir  mouth."'  Quite  naturally  there  is  more 
or  less  difficulty  in  speech,  control  of  saliva,  drinking,  and  other  acts 
which  depend  upon  the  lips.  There  are  no  fibrillary  twitchings,  no 
disturbance  of  sensibility,  and  there  is  gradual  decrease  of  mechanical 
muscular  excitability. 

Prognosis. — The  prognosis  in  muscular  dystrophy  is  generally 
regarded  as  unfavorable,  and  it  is  expected  that  in  some  forms  of  the 
disease  there  will  be  a  continued  although  not  rapid  progress,  which 
by  extension  from  muscle  to  muscle  will  ultimately  bring  about  a 
condition  of  complete  paralysis.  The  hopeful  feature  lies  in  the  fact 
that  this  does  not  always  occur,  and  that  after  a  time  the  progress  of 
the  disease  ceases.  Death  usually  occurs  through  the  development 
of  some  complicating  condition  or  paralysis  of  the  respiratory  appa- 
ratus. 

Treatment. — The  treatment  advised  is  in  the  nature  of  general 
measures  to  improve  health  and  nutrition,  fresh  air,  well-selected, 
nourishing  food,  exercise,  massage,  with  avoidance  of  unusual  fatigue. 

The  author  has  deemed  it  important  to  include  muscular  dystrophy 
among  the  affections  ^\  hich  bear  an  important  relation  to  the  oral  and 
facial  regions,  because  in  a  large  nimiber  of  cases  under  his  care  and 
observation  irregular  dental  arches,  high,  narrow  palatal  vaults,  and 
the  nasal  defects  which  are  usually  associated  in  individuals  so  affected 
have  been  coincident  with  as\'mmetrical  muscular  development  in 
other  parts  of  the  body,  ^^^lether  these  cases  should  have  been 
properly  classified  under  any  of  the  several  forms  of  muscular  dys- 
trophy is  perhaps  to  some  extent  questionable  on  account  of  incomplete 
history  and  diagnosis.  But  there  can  be  no  doubt  of  the  fact  that  the 
factors  leading  to  irregular  or  imperfect  development  in  other  divisions 
of  the  body  can  be  in  like  degree  influential  in  making  for  irregular 
development  of  the  jaws  and  face.  Again,  it  is  equally  true,  and  fully 
demonstrable  from  innumerable  cases  in  practice,  that  with  proper 
ex-pansion  of  the  palatal  arches  by  separation  of  the  upper  maxillte  at 
the  median  suture,  and  the  widening  of  the  nares  invariably  following 
this  procedure,  the  first  result  is  an  improvement  in  nasal  respiration 


DISEASES  OF  THE  SPINAL  CORD  205 

and  increased  healtlifulness  of  intranasal  tissues,  with  attendant 
marked  general  inipro\'ement  of  health,  nervous  and  other  governing 
influences.  When  supplemented  by  proper  form  of  the  dental  arches 
and  correct  occlusion  of  the  teeth,  it  gives  at  least  reasonably  good 
promise  for  the  betterment  of  developmental  influences.  We  have, 
therefore,  in  the  region  of  the  mouth  and  jaws  not  only  an  index  of 
individual  tendency  to  imperfect  or  asymmetrical  growth,  but  a  promis- 
ing opportunity  for  directly  benefiting  predisposing  conditions,  and  this 
is  certainly  worthy  of  consideration  in  every  instance. 

Without  doubt  many  cases  which  dentists  treat  for  the  correction 
of  dental  irregularities  are  merely  expressions  of  some  more  general 
affection.  Although  the  regulation  of  the  teeth  does  have  a  wider 
beneficial  influence  than  is  usually  contemplated  when  such  procedures 
are  undertaken,  a  more  general  examination  of  the  developmental  con- 
ditions of  such  patients  would  undoubtedly  lead  to  detection  of  many 
diseases  at  an  early  stage  when  curative  treatment  could  be  successfully 
applied  and  the  influence  of  mouth  treatment  be  much  extended  in  its 
beneficial  aspect. 

Just  where  the  line  of  demarcation  should  be  drawn  in  every  instance 
between  muscular  atrophy,  which  notes  the  beginning  of  a  progressive 
condition  that  may  be  expected  to  lead  on  to  paralysis,  and  one  of 
such  character  that  its  progress  ^ill  be  arrested  in  natural  course  with- 
out necessarily  causing  a  state  of  helplessness  and  endangering  life, 
is  often  difficult  to  decide.  It  must  also  be  more  or  less  a  matter  of 
speculation,  when  the  progress  of  the  disease  has  ceased  during  treat- 
ment with  apparent  restoration  or  increased  usefulness  of  the  affected 
parts,  to  determine  just  how  much  or  how  little  the  actual  remedial 
measures  may  have  accomplished.  While  the  author  fully  appreciates 
these  facts,  he  believes  (1)  that  the  centers  governing  trophic  changes, 
especially  when  these  show  pathological  alterations  in  the  region  of  the 
face  and  jaws,  may  be  directly  benefited  by  maxillary  separation,  which, 
as  already  stated,  relieves  nerve  tension  and  compression  in  the  region 
of  the  jaws  and  teeth,  widens  the  nares,  and  thus  makes  possible  better 
respiration;  (2)  that  in  young  persons  it  is  only  reasonable  to  expect 
the  effect  of  expansion  in  the  lower  regions  of  the  face  to  favor  also 
greater  freedom  of  growth  in  the  higher  structures  at  the  base  of  the 
skull  in  which  are  situated  the  larger  foramina  through  which  the 
cranial  nerves  and  their  important  accompanying  vessels  emerge, 
compression  of  any  one  of  which  would  be  capable  of  causing  both 
local  and  general  disturbances  of  far-reaching  character;  (3)  that  it  is 
not  impossible  for  this  influence  to  extend  still  higher  until  it  could 
affect  the  form  of  the  sella  turcica  in  which  the  pituitary  body  is  situ- 
ated and  thus  reach  the  hypophysis  which  is  now  recognized  as  an 
influential  factor  in  aberrations  of  growth ;  and  (4)  that  in  this  way  the 
vegetative  nervous  ganglia  of  the  nose  and  respiratory  tract  are  stimu- 
lated as  the  nares  become  enlarged,  and  nasal  respiration  secured.  In 
due  course  the  ciliary,  otic,  and  sphenopalatine  ganglia  are  affected, 


206 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


and  through  these  the  balance  of  control  between  the  sympathetic  and 
the  vagus  systems  is  regulated  in  such  manner  as  to  establish  a  widely 
beneficial  result.  Thus  the  endocrin  (so-called  ductless  gland)  organs 
become  included  with  other  corrective  influences  on  nervous,  circula- 
tory, digestive  and  glandular  physiological  activities.  Without  desire 
to  urge  unduly  AA'hat  in  our  present  state  of  knowledge  must  be 
admitted  to  be  largely  theoretical,  the  author  presents  brief  descriptions 
of  two  of  his  cases  (P'igs.  98,  99,  100  and  101).  It  will  be  seen  that  they 
bear  indications  of  dental  and  facial  irregularity  of  development  of  not 
uncommon  type,  yet  further  study  of  their  histories  and  symptoms 
reveals  the  fact  that  they  undoubtedly  belong  to  the  class  of  muscular 
dystrophy,  while  the  results  of  treatment  are  apparent  in  both  general 
and  local  improvement. 


Fig.  98. — Girl,  aged  sixlccn  \i':irs,  witli  symptoms  of  the  Erb  type  of  juvenile  dys- 
trophy, associated  with  nasal  and  maxillary  defects,  who  was  greatly  benefited  by  maxil- 
lary extension.     (Described  as  Case  I  in  text.) 

Analysis  of  Two  Cases. — Case  I  (Fig.  98). — The  patient  was  a  girl, 
aged  sixteen  years.  History. — Three  operations  had  previously  been 
performed  for  the  removal  of  nasopharyngeal  adenoids,  with  apparent 
recurrence  after  each  operation.  On  account  of  general  ill  health, 
nervousness,  and  frequent  colds,  attended  by  evidences  of  both  local 
and  general  arrest  of  development,  the  patient  had  for  some  time  been 
unable  to  attend  school  continuously  and  suffered  frequent  illness. 

Symptoms  and  General  Appearance.- — Height,  5  feet  2  inches,  weight 
92|  pounds.  INIore  or  less  other  indication  of  insufficient  development. 
Marked  inequality  of  development  in  the  region  of  the  shoulder-blades, 
closely  approximating  if  not  identical  with  the  Erb  type  of  juvenile 
dystrophy.  This  was  so  evident,  her  mother  said,  that  the  dressmakers 
had  considerable  difficulty  in  fitting  her  dresses.  Marked  nasal  obstruc- 
tion, arrested  development  of  the  lower  part  of  the  face,  receding  chin, 
and  contracted  upper  and  lower  dental  arches.    Two  superior  bicuspids 


DISEASES  OF  THE  SPINAL  CORD  207 

had  been  removed  (one  on  each  side)  by  some  dentist,  with  the  mis- 
taken idea  of  correcting  dental  irregularity.  When  she  was  about 
nine  years  old  the  spaces  thus  caused  were  almost  completely  closed 
by  contraction  of  the  upper  dental  arch.  One  lower  bicuspid  on  the 
right  side  had  been  extracted  about  the  same  time  with  the  same  effect. 

Treatment. — The  upper  maxilhe  were  readjusted  by  maxillary  ex- 
pansion and  the  lower  arch  made  to  correspond.  Both  arches  were 
increased  in  an  anteroposterior  direction  sufficiently  to  regain  insofar 
as  possible  the  space  lost  through  extraction  of  the  teeth,  after  which  a 
dentist,  Dr.  P.  B.  ^Yright,  of  ^lilwaukee,  inserted  bridge-work  to  retain 
the  full  size  of  the  jaws  thus  secured. 

Result  of  Treatment. — As  a  result  of  this  treatment,  which  was  begun 
in  October,  1906,  there  was  improvement  in  facial  symmetry  and 
widening  of  the  nares,  which  made  better  respiration  possible.  Coin- 
cident with  this  there  was  marked  decrease  of  nervous  SATuptoms,  so 
much  so  that  the  patient  was  able  to  go  on  with  her  studies,  and  in  due 
course  graduated  with  honors  from  the  high  school.  Growth  in  height 
and  increase  in  weight  began  almost  immediately.  September  2,  1910, 
her  weight  was  107^  pounds  and  her  height  5  feet  3  inches.  Her  mother 
reported  that  they  no  longer  had  difficulty  in  fitting  her  dresses,  because 
the  maldevelopment  of  her  shoulders  had  disappeared. 

Conclusions. — The  author  is  aware  that  in  consideration  of  the  prog- 
nosis as  generally  understood  with  regard  to  the  Erb  t^-pe  of  muscular 
dystrophy,  and  in  view  of  the  later  improvement  of  the  muscular 
deformity,  there  may  be  question  as  to  this  being  a  true  case  of  this 
affection.  But  without  desire  to  claim  too  much,  the  fact  that  this 
young  woman  had  for  a  time  during  the  course  of  treatment  a  facial 
paralysis  of  short  duration,  and  taking  into  account  all  the  other 
s;\Tnptoms,  there  is  at  least  sufficient  evidence  to  warrant  the  belief 
that  her  condition  was  one  at  least  closely  akin  to  muscular  dystrophy, 
and  that  through  the  restoration  of  general  health  and  improvement 
by  renewal  of  constructive  trophic  changes  continued  degenerative 
progress  was  averted. 

Case  II  (Figs.  99,  100  and  \Ql).— History.— i:\ve  patient  in  this 
case  was  a  boy,  aged  ten  years.  He  had  been  a  mouth-breather  for 
a  long  time,  had  scarlet  fever,  a  sequela  of  which  was  evidenced 
by  neuritis  "extending  around  his  head,"  and  he  had  for  a  long  time 
enlarged  glands  upon  both  sides  of  the  neck.  Bodily  growth  for  a  time 
seemed  to  be  normal,  but  for  some  time  had  not  been  progressing  as 
expected.  He  was  unable  to  attend  school  continuously  when  treat- 
ment was  begun. 

Symj)toms. — Both  upper  and  lower  arches  were  markedly  con- 
tracted. Arrested  development  of  the  lower  part  of  the  face,  particu- 
larly in  the  region  of  the  lower  jaw,  caused  marked  recession  of  the 
chin.  The  nose  was  slightly  to  the  right  of  the  central  facial  line. 
There  was  an  appearance  of  depression  on  the  left  side  of  the  nose, 
including  the  malar  region,  with  corresponding  appearance  of  h^-per- 


208 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


trophic  development  of  the  same  regions  on  the  opposite  side  of  the 
face.    The  thumb  and  pahii  of  the  left  hand  (Figs.  100  and  101)  showed 


Fig.  99. — Boy,  aged  ten  years,  described  in  the  text  as  Case  II.  With  unequal  facial 
development,  indicating  tendency  to  hemiatrophy,  tapir  mouth,  and  other  symptoms 
of  the  Landouzy-Dejerine  type  of  muscular  dystrophy.  Dystrophy  of  the  muscles  of 
the  shoulders  and  back,  indicative  of  Erb's  juvenile  form  of  muscular  dystrophy.  Thumbs, 
palms,  and  hands  and  feet  affected,  as  in  progressive  muscular  dystrophy,  but  without 
fibrillary  twitching.  In  this  case  tendency  to  normal  growth  was  apparent  immediately 
after  separation  of  the  maxillfe  by  expansion  of  his  dental  arches. 


/l 

^ 

>- 

^ 

/  X 

Mr 

^^ 

m" 

Fig.  100  Fig.  101 

Figs.  100  and  101. — The  palms  of  both  hands  of  the  boy  shown  in  Fig.  99.  Waste  of 
the  thenar  eminences.  The  altered  position,  form  and  size  of  the  thumb  may  be  noted 
in  Fig.  100. 


DISEASES  OF  THE  SPIXAL  CORD 


209 


marked  asymmetry  of  development.  The  thmnb  was  believed  to  have 
been  injured  in  infancy.  The  lips  hung  loose,  the  mouth  was  habitually 
open,  with  appearance  much  resembling  the  "tapir  mouth"  of  the 
Landouzy-Dejerine  t^-pe  of  muscular  dystrophy. 

Treatment. — The  treatment  consisted  in  expansion  of  both  upper 
and  lower  dental  arches  with  separation  of  the  maxillse,  and  in  this 
wav  widening  the  nares. 


Fig.  102. — Boy,  aged  eight  years,  desfribed  in  text  as  Case  III.  His  face  shows 
unequal  facial  development.,  nose  insufficiently  developed,  maxillae  contracted;  dental 
arches  irregular;  mouth-breather;  one  side  of  the  mouth  lower  than  the  other,  affection 
of  the  risorii  muscles  and  characteristic  appearance  of  chest  and  shoulders. 

Result. — This  treatment  promptly  improved  his  nasal  breathing  and 
has  overcome  to  some  extent  at  this  date,  eighteen  months  after  treat- 
ment was  begun,  the  relaxed  condition  of  the  lips,  for  the  mouth  no 
longer  hangs  open  as  it  formerly  did,  and  there  is  apparently  going  on 
a  normal  growth  which  is  overcoming  the  asymmetrical  appearance  of 
the  face,  quite  outside  of  alterations  in  facial  appearance  that  might 
be  expected  from  regulation  of  the  dental  arches  alone.  Nervous- 
ness has  almost  entirely  disappeared,  and  general  health  is  also  much 
14 


210'  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

improved.  He  has  for  some  time  been  regularly  pursuing  his  studies, 
and  appears  in  all  respects  to  be  quite  normal.  (Later  report.)  In  an 
eastern  preparatory  school  this  lad  has  led  his  class  in  both  scholarship 
and  athletics  for  two  or  more  years. 


Fig.  103. — Presents  the  back  view  of  the  same  boy  shown  in  Fig.  102.     The  typical 
difference  in  the  shoulder-blades  and  the  spinal  curvature  may  be  noted. 

Case  III. — The  boy  illustrated  in  Figs.  102  and  103  is  another  of  the 
author's  patients  whose  back,  nose,  and  palate  attest  a  tendency  to 
muscular  atrophy. 

In  this  case  also  there  was  marked  improvement  in  growth  and 
general  health  as  soon  as  the  upper  maxillpe  were  separated  and  nasal 
conditions  thus  improved. 

Conclusions. — In  these  cases,  as  in  the  one  previously  described,  the 
author  presents  the  facts  with  suggestions  of  diagnosis  rather  than  a 
desire  to  assume  a  dogmatic  position.  But  v/ith  the  great  mass  of  other 
examples  that  might  be  cited  to  enhance  the  importance  of  the  clinical 
evidences  of  these  cases,  the  author  unhesitatingly  urges  the  great 


SPINAL  DISEASES  211 

possibilities  of  furthering  constructive  development  in  all  respects  and 
assisting  to  check  progressive  degenerative  conditions,  whether  purely 
muscular  or  of  nervous  origin,  by  treatment  such  as  described  in  these 
and  other  cases,  as  discussed  more  in  detail  on  pages  550  and  556. 

OTHER   SPINAL  DISEASES  IN  WHICH   SYMPTOMS   SOMETIMES 
EXTEND  TO  THE  FACE,  MOUTH  AND  JAWS. 

Acute  Progressive  Paralysis ;  Landry's  Paralysis. — This  is  an  actite, 
rapidly  progressing,  ascending  paralysis,  usually  fatal,  but  in  rare 
instances  recovery  has  been  reported. 

Etiology. — Its  symptoms  and  frequent  association  with  infectious 
diseases,  in  the  absence  of  definite  knowledge  to  the  contrary,  led  to 
the  belief  that  it  is  simply  an  evidence  of  acute  infection.  Autopsies 
have  repeatedly  demonstrated  changes  in  the  viscera,  li\'er,  kidneys, 
and  lymph  glands. 

Pathology. — Changes-  in  the  spinal  cord  have  been  noted  which 
include  acute  myelitis,  yerimscular  and  inflammatory  conditions,  acute 
degenerative  processes,  and  sometimes  pathogenic  microorganisms,  but 
no  special  germ.  Also  lesions  of  the  nerves  and  in  the  neuron  bodies, 
as  well  as  in  the  pons  and  in  the  cerebral  axis. 

Symptoms. — Beginning  with  the  lower  extremities,  the  paralysis 
usuall}'  is  accompanied  by  numbness,  and  rarely  with  pain  without 
tremor,  muscular  contraction,  or  spasm,  and  progresses  rapidly  until 
the  bulbar  region  is  reached.  The  muscles  of  deglutition,  speech,  and 
of  the  face  become  totally  paralyzed,  as  do  the  other  portions  of  the 
body.  There  may  or  may  not  be  sensory  disturbance,  but  consciousness 
remains  clear. 

Prognosis. — Prognosis  is  grave.  Death  usually  results  in  from  a  few 
days  to  t^^o  weeks. 

Treatment. — Treatment  is  practically  unavailing,  but  such  as  may 
be  attempted  must  be  directed  to  relief  of  the  primary  infection  and 
the  distressing  symptoms,  as  "\^ell  as  to  give  prompt  general  support. 

Locomotor  Ataxia. — This  is  a  chronic  disease  of  the  sensory  portion 
of  the  ner\'ous  system. 

Etiology. — Its  most  common  cause  is  syphilis,  although  exposure  to 
cold,  overexertion,  traumatism,  excessive  use  of  alcohol,  and  other 
factors  are  undoubtedly  influential  in  this  relation. 

Pathology. — The  posterior  spinal  ganglia  and  ganglia  of  the  cranial 
nerves  are  first  affected.  The  sympathetic  ganglia  are  sometimes 
included.  The  axons  of  the  neuron  bodies  of  these  ganglia  undergo 
various  forms  of  degeneration. 

Symptoms. — The  physical  manifestations  of  this  affection  are  numer- 
ous and  varied.  There  is  a  first  stage  of  pain  or  paresthesia,  a  second 
stage  of  ataxia  or  imperfect  coordination  of  muscular  action,  and  a 
third  stage  of  paralysis.  Among  the  rare  s\T2iptoms  we  find  bulbar 
paralysis  resulting  from  continued  progress  of  the  disease,  with  the 


212  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

usual  facial,  lingual,  and  other  symptoms  in  this  region,  also  blindness 
and  other  indications  of  affections  of  the  cranial  nerves.  Hemiatrophy 
of  the  tongue  sometimes  occurs,  or  there  may  be  muscular  atrophy 
affecting  facial,  buccal,  lingual,  and  palatal  muscles  or  other  muscles 
of  the  body. 

Diagnosis. — While  the  general  aspect  of  the  disease  requires  differen- 
tiation from  multiple  neuritis,  neurasthenia,  diseases  of  the  cerebellum, 
general  paresis,  and  other  similar  affections,  the  somewhat  rare  cases 
having  manifestations  in  the  mouth  and  face  would  by  reason  of  their 
history  be  readily  distinguished. 

Treatment. — Treatment  is  practically  unavailable  from  a  curative 
point  of  view.  Such  therapeutic  measures  as  may  assist  in  arresting 
progress  of  the  disease  are  indicated  as:  Change  of  climate,  regulation 
of  diet,  suitable  exercise,  massage,  baths,  counter-irritation,  electricity, 
etc.  ^Mien  syphilis  is  known  to  be  the  cause,  antisyphilitic  treatment. 
(See  S^'philis,  page  107). 

Friedreich's  Ataxia. — A  disease  appearing  in  childhood,  characterized 
by  development  of  the  spinal  cord  with  affections  of  the  neuroglia 
tissue  which  supplants  the  defective  or  degenerative  fibers.^  First 
described  by  Friedreich,  in  Heidelberg,  in  1863  and  1876.  Schultz,  in 
1877,  showed  that  the  disease  is  not  related  in  any  way  to  locomotor 
ataxia,  but  due  to  a  defective  development  of  the  spinal  cord. 

Etiology. — Heredity  seems  to  have  an  influence,  since  it  occasionally 
happens  that  members  of  the  same  family  are  affected.  Infectious 
diseases  of  childhood  are  at  least  predisposing  factors.  Alcoholism 
and  syphilis  in  the  parents  are  a  parental  heritage  or  active  influence. 

Pathology. — The  spinal  cord  in  these  cases  appears  thin  and  small, 
with  thinning  of  the  pia  mater.  There  is  thinning  of  tissue  in  the  pos- 
terior and  lateral  columns  of  the  spinal  cord,  with  extensive  degenera- 
tion of  the  nerve  fibers  and  changes  in  the  gray  matter  of  the  cord. 

Symptoms. — The  affection  may  be  congenital,  or  symptoms  may 
develop  gradually  about  the  sixth  or  eighth  year.  In  congenital  cases 
the  children  learn  to  walk  with  difficulty,  if  at  all,  are  unsteady  upon 
their  feet,  fall  easih;,  and  have  tendency  to  stagger.  Feet  are  far  apart, 
steps  short  and  unsteady,  with  difficulty  in  preserving  balance.  The 
speech  is  slow,  difficult,  and  indistinct. 

In  the  author's  practice  a  considerable  number  of  hare-lip  and  cleft- 
palate  infants  have  given  evidence  of  arrested  development  of  the 
spinal  cord  in  association  with  the  defective  development  which  caused 
hare-lip  and  cleft-palate.  In  these  case  some  of  the  children  failed  to 
learn  to  walk  at  all  until  three  or  four  years  old,  and  even  the  -gait 
presented  the  characteristic  uncertainty.  There  was  the  usual  speech 
difficulty  ^^■hich  always  accompanies  cleft-palate,  but  even  after  the 
palates  were  closed  there  remained  the  slowness  of  speech,  difficulty  in 
learning  to  use  the  tongue,  and,  above  all,  a  disinclination  to  make 

1  Starr:  Nervous  Diseases,  Organic  and  Functional,  4th  ed.,  p.  388. 


SPIXAL  DISEASES  213 

speech  effort.  In  contradistinction  to  the  usual  description  of  such 
patients  it  was  found  that  some  of  these  children  appeared  to  be 
unusually  britrht.  Others  had  the  stupirl  ai)pearance  of  the  weak- 
minded. 

Diagnosis. ^This  is  usually  not  difficult.  The  appearance  of  the 
characteristic  s\'mptoms  before  five  or  six  years  of  age  in  most  cases, 
or  even  later  than  sixteen  years,  is  important. 

Children  are  seldom  ever  affected  by  locomotor  ataxia.  Multiple 
neuritis  is  readily  excluded  by  history  of  the  case.  Ataxia  from  cere- 
bellar disease  occurs  later  in  life. 

Prognosis. — In  Friedreich's  ataxia,  as  generally  understood,  the 
prognosis  is  unfavorable,  and  a  gradually  progressive  increase  of 
sjTuptoms  may  be  expected  until  the  child  is  quite  crippled  from 
paralysis,  and  although  the  affection  itself  is  not  fatal,  susceptibility 
to  other  disease  often  brings  early  death. 

The  author  has  observed  a  considerable  number  of  defective  infants 
and  children  with  s^^Hptoms  quite  similar  to  those  of  Friedreich's 
ataxia,  and  he  believes  that  other  forms  of  affections  of  this  character 
which  signify  less  serious  conditions  should  be  recognized.  Othervs'ise 
it  does  not  necessarily  follow  that  degenerative  processes  must  steadily 
continue,  for  "\\ith  correction  of  the  external  defects  and  proper  general 
care  many  of  these  patients  seem  to  show  a  tendency  to  outgrow  the 
deficiency  to  some  extent,  and  do  learn  to  use  the  affected  muscles  in 
speech  and  movement  with  decided  improvement. 

Treatment. — Xo  regular  treatment  can  be  depended  upon.  If  the 
cases  be  of  such  character  as  those  already  described,  patient  upbuilding 
of  general  health  and  the  steady  cultivation  of  the  affected  muscles 
may  do  much,  and  is  at  least  worth  an  effort. 

Myelitis. — Hyperemia,  anemia,  and  myelitis  of  the  cord  are  affec- 
tions that  relate-to  conditions  of  the  blood  and  to  infection  which  by 
reason  of  this  fact  are  necessarily  more  or  less  closely  associated  with 
diseases  of  the  mouth. 

Symptoms. — The  degenerative  conditions  of  the  cord  in  acute  and 
chronic  myelitis  cover  a  wide  range.  They  include  paralysis  of  the 
parts  of  the  body  supplied  by  the  spinal  nerves,  trophic  changes,  and 
finally  affections  of  speech,  facial  paralysis,  and  other  indications  that 
the  disease  has  extended  to  the  bulbar  region. 

Prognosis. — The  prognosis  is  unfavorable.  Usually  such  patients 
become  chronic  invalids. 

Treatment. — Treatment  is  to  support  the  general  health,  give  the 
patient  such  comfort  as  may  be  possible,  and  to  guard  against  com- 
plicating disease  which  may  hasten  death.  Other  measiu-es  which  are 
recommended  for  spinal  diseases  are  to  some  extent  applicable  in  these 
cases. 

Pachymeniiigitis  Cervicalis  Hypertrophica. — This  is  a  disease  of 
rapid  progress,  presenting  the  symptoms  of  myelitis  of  the  cervical 
region. 


214  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Pathology. — Compression  of  the  cord  results  from  fibrous  thickening 
of  the  dura  mater,  which  also  affects  the  nerve  roots  in  their  passages 
through  the  dura. 

Symptoms. — This  affection  is  of  particular  importance  to  our  subject 
because  its  early  symptoms  may  easily  be  mistaken  for  evidences  of 
other  disease?.  In  the  first  stage  there  is  pain  in  the  back  of  the  neck 
and  head,  with  stiffness  of  the  neck,  but  the  fact  that  pain  is  also  felt 
in  the  hands  and  arms  serves  to  distinguish  this  from  other  causes  of 
pain  in  the  back  of  the  head  and  neck.  In  the  second  stage  there  are 
muscular  contractions,  and  in  the  third  stage  paralysis. 

Prognosis. — The  prognosis  is  fairly  good  if  the  disease  be  diagnosti- 
cated in  its  early  stage.  The  responsibility  of  the  oral  surgeon  for 
prompt  reference  of  such  cases  for  immediate  proper  treatment  is 
therefore  important. 

Treatment. — Treatment  consists  of  mercury  and  iodide  of  potash  in 
large  doses,  since  the  cause  of  the  affection  is  presumed  to  be  syphilis. 
The  actual  cautery  is  also  applied  to  the  back  of  the  neck,  and  remedies 
are  given  for  the  relief  of  pain. 

Spinal  Meningitis. — Etiology. — This  is  an  acute  meningitis,  limited 
to  the  spinal  cord,  which  develops  after  various  forms  of  disease  of  the 
spinal  column  or  dura  mater.  It  follows  spinal  injuries  and  other  dis- 
eases of  the  spinal  cord,  but  its  most  frequent  causes  are  infectious 
diseases  ranging  from  comparatively  simple  infections  through  pneu- 
monia, typhoid,  septicemia,  etc.    Its  forms  are  acute  or  chronic. 

Symptoms. — Acute  meningitis  develops  suddenly  with  fever,  chill, 
malaise,  nausea,  and  other  symptoms  of  acute  infection.  Pains  in  the 
head,  back,  and  limbs  are  followed  by  stiffness  of  the  back  and  neck 
and  rigidity  of  the  body.  Hyperesthesia  of  the  skin  surface,  muscular 
spasms,  and  twitchings  are  followed  by  anesthesia  and  paralysis  as  the 
degeneration  progresses,  ^^asomotor  disturbances,  trophic  changes, 
etc. 

Chronic  cases  quite  closely  resemble  the  acute  except  that  the  onset 
is  less  marked  and  symptoms  due  to  changes  occurring  through  longer 
continuance  of  a  somev\'hat  wider  range. 

Diagnosis.— Diagnosis  is  best  accomplished  by  lumbar  puncture. 
Usually  the  spinal  fluid  contains  leukocytes  and  bacteria  of  various 
kinds  which  are  representative  of  the  character  of  infection. 

Prognosis. — The  prognosis  depends  largely  upon  the  character  and 
influence  of  its  septic  cause. 

Treatment. — Treatment  consists  in  rest  in  bed,  relief  of  the  symp- 
toms, applications  of  heat,  plasters,  or  actual  cautery  along  the  spine. 
Sedative  and  general  treatment  should  be  appropriate  to  the  infection. 

Its  chief  interest  to  our  subject  lies  in  the  possibility  of  the  influence 
of  mouth  infection  and  recognition  of  its  symptoms  in  difterential 
diagnosis. 


DISEASES  OF  THE  BRAIN  215 


DISEASES  OF  THE  BRAIN. 


Cerebral  Diseases. — Cerebral  Hemorrhage,  Cerebral  Embolism,  and 
Cerebral  Thrombosis.^ — These  are  chiefly  important  to  the  oral  surgeon 
from  a  symj^tomatological  point  of  view,  because  among  the  symp- 
toms headache  is  one  of  the  most  common  premonitory  evidences 
of  these  affections,  particuhirly  with  endarteritis.  Plethoric  indi- 
viduals with  much  redness  of  the  face  and  distention  of  the  veins  may 
be  the  subjects;  in  other  cases  they  are  pale,  ill-nourished  persons, 
the  sufferers  of  existing  diseases,  weak  hearts,  and  similar  conditions. 
Headache  of  this  character  commonly  affects  the  frontal  or  occipital 
regions.  It  is  usually  bilateral  and  varying  in  intensity,  and  must  needs 
be  distinguished  from  headache  due  to  other  causes.  When  hemor- 
rhage, embolism,  or  thrombosis  is  followed  by  paralysis,  the  tongue, 
face,  and  palate  are  included  in  the  hemiplegia,  the  muscles  about  the 
eye  that  close  the  lids  being  the  only  ones  which  are  not  involved,  thus 
distinguishing  this  form  of  facial  paralysis  from  that  due  to  affections 
of  the  facial  nucleus  in  the  pons  or  of  the  facial  nerve. 

Intracranial  Pressure.^ — Symptoms. — When  the  contents  of  the 
skull  are  slowly  increased  by  a  small  tumor  or  by  a  small  clot,  the 
displacement  of  cerebrospinal  fluid  and  the  narrowing  of  the  veins 
prevent  tangible  effects.  But  when  a  large  clot  suddenly  forms,  the 
pressure  causes  venous  stasis  and  a  slowing  of  capillary  circulation. 
Nature  in  attempting  correction  raises  the  arterial  tension,  and  thus 
maintains  the  nutrition  of  the  medullary  centers  necessary  to  life. 
If  the  pressure  is  increased  beyond  the  power  of  adjustment  of  the 
heart,  then  a  weak,  rapid  heart  action,  a  relaxed  arterial  tension, 
and  an  irregular  respiration  are  followed  by  collapse  and  death. ^ 
Arterial  tension  therefore  indicates  the  degree  of  intracranial  pressure. 
A  tension  of  220  mm.  developed  suddenly  is  dangerous  and  a  tension  of 
280  is  fatal. 

Treatment. — Decompression  is  the  only  means  of  relieving  intra- 
cranial pressure  when  the  arterial  tension  rises  to  the  danger  point.^ 

Hemiplegia. — Hemiplegia  may  be  defined  as  paralysis  of  motion 
of  one  side  of  the  body,  usually  due  to  cerebral  diseases  and  occasion- 
ally due  to  injury  or  disease  of  the  spinal  cord. 

Cerebral  Spastic  Paralysis. — Etiology. — This  disorder  results  from 
maldevelopment.  Atrophy  or  injury  to  the  brain  from  any  cause  may 
give  rise  to  s>^nptoms  of  hemiplegia. 

Symptoms. — Cerebral  spastic  paralysis  may  develop  in  infancy  and 
be  attended  by  high  fever  (temperature  102°  to  105°  F.),  nausea, 
vomiting,  headache,  and  delirium;  in  the  case  of  older  persons  it  may 
be  associated  with  feeble-mindedness,  imbecility,  idiocy,  blindness, 
deaf-mutism,  and  epilepsy.     The  paralysis  may  affect  the  face  and 

'  Starr:   Nervous  Diseases,  Organic  and  Functional,  4th  ed.,  p.  466. 

2  Kocher  Hirndruck,  Nothnagel's  spec.  Path,  und  Ther.,  ix,  32. 

3  Gushing:  Am.  Jour.  Med.  Sc,  September,  1902,  and  June,  1903. 


216  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

jaws  in  common  with  other  anatomical  regions,  or  there  may  be  spastic 
rigidity  or  athetosis  (inabihty  to  retain  the  fingers  in  any  spastic  posi- 
tion in  which  they  are  placed,  the  constant  state  of  slow  movement  of 
fingers  and  toes,  flexion,  extension,  etc). 

In  these  cases  the  athetoid  movements  may  aflfect  the  face  and 
tongne,  causing  constant  grimaces  and  interfering  with  speech,  or 
there  may  be  choreic  movements  more  violent  than  athetosis.  Starr^ 
describes  a  case  with  total  paralysis  of  the  tongue  and  right  hemi- 
plegia. This  child  at  the  age  of  twelve  years  was  still  unable  to  articu- 
late, and  food  was  pushed  into  the  throat  b}^  the  finger  and  then 
swallowed. 

Treatment. — An  attempted  description  of  the  treatment  of  these 
cases  would  be  quite  outside  the  purpose  of  this  volume.  This  refer- 
ence is  included  because  the  symptoms  which  affect  the  face  and  jaws 
sometimes  require  to  be  differentiated  from  other  pathological  states 
causing  similar  paralysis.  Moreover,  a  field  is  developing  which 
promises  useful  results  in  the  differential  diagnosis  of  mental  defects. 
This  applies  particularly  to  the  distinction  between  aphasia  (partial 
or  complete  loss  of  the  use  of  language  by  the  tongue  or  pen) ,  a  common 
associate  of  right  hemiplegia,  and  the  inability  to  pronounce  certain 
words  and  other  evidences  of  defective  brain-cell  development  due 
primarily  to  arrested  development  of  the  jaws  or  disproportion  between 
the  size  of  the  tongue  and  its  maxillary  and  palatal  enclosures.  In 
the  latter  case  the  large  size  of  the  tongue,  in  comparison  with  the  jaws 
in  embr}^o,  makes  its  proper  use  in  word-forming  exceedingly  difficult, 
or  impossible  if  later  growth  of  the  jaws  be  arrested.  Children,  there- 
fore, with  large  tongues  and  narrow  or  otherwise  deformed  palatal 
vaults  can  only  learn  to  speak  certain  words  with  great  difficulty  if  at 
all.  Undoubtedly  this  disadvantage  causes  disinclination  to  make  the 
attempt,  thus  the  necessary  brain  centers  are  not  properly  stimulated 
to  activity.  As  a  result  an  individual  in  the  course  of  time  becomes 
really  defective,  although  in  the  beginning  imperfect  form  of  the  parts 
and  organs  concerned  in  speech,  which  could  have  been  readily  cor- 
rected if  properly  diagnosticated,  was  chiefly  responsible  for  the  ill- 
developed  brain  which  later  became  evident.  It  must,  of  course,  be 
understood  that  these  stigmata  of  degeneracy,  as  Talbot^  has  so  lucidly 
explained,  quite  commonly  go  hand  in  hand.  The  mouths  of  idiots, 
epileptics,  and  other  children  are  characteristically  contracted  and 
ill-formed  because  the  irregular  cell  development  affects  these  and 
other  parts  as  well  as  the  brain.  Nevertheless  it  is  a  matter  of  utmost 
importance  that  no  factor  be  allowed  to  interfere  with  brain  growth, 
and  every  impediment  to  proper  mental  training  be  removed.  To  this 
end  recognition  and  distinction  between  affections  which  might  by  any 
possibility  act  as  predisposing  or  exciting  causes  should  be  emphasized. 
Proper  expansion  of  the  dental  arches,  which  widens  also  the  almost 

1  Nervous  Diseases,  Organic  and  Functional,  4th  ed.,  p.  524. 
.    2  Stigmata  of  Degeneracy,  Etiology  of  Osseous  Deformities. 


DISEASES  OF  THE  BRAIN  217 

in\ariably  associated  contracted  nares,  and  the  surgical  correction, 
if  necessary,  of  any  defectively  formed  parts,  should  receive  due  con- 
sideration and  become  a  matter  of  routine  procedure. 

Encephalitis;  Cephalitis.^ — By  this  term  is  meant  inflammation  of 
the  hraiii  in  contradistinction  to  that  of  the  nieml)rane  of  the  brain. 

Etiology. — The  general  opinion  seems  to  be  that  it  is  an  acute 
infectious  disease.  There  is  some  question  as  to  \\hether  or  not  it 
could  be  caused  by  an  injury  to  the  head  without  fracture  or  menin- 
gitis, as  it  is  usually  only  after  the  invasion  of  bacteria  that  bruises  in 
the  soft  tissues  of  the  brain  are  followed  by  inflammation.  The  patho- 
logical conditions  A\ith  ^^■hich  it  is  etiologically  associated  are  scarlet 
fever,  influenza,  pneumonia,  erysipelas,  whooping-cough,  mumps, 
diphtheria,  ulcerative  endocarditis,  otitis  media,  and  septicemia. 
Ptomain  poisoning,  alcoholism,  syphilis  and  similar  causes  also  bear 
an  important  relation.  Infection  from  diseased  conditions  of  the  mouth, 
whether  carried  directly  through  circulatory  or  l\Tnphatic  channels 
or  by  extension  of  disease  through  associated  sinuses,  is  a  matter  of 
important  consideration,  particularly  as  this  disease  occurs  most  often 
in  children  and  young  people,  and,  as  is  well  known,  the  mouths  of 
most  children,  except  under  unusually  rare  conditions,  almost  always 
contain  diseased  teeth  or  gums,  or  both,  to  predispose  to  such  in- 
fection. 

Pathology. — The  changes  in  brain  structure  may  be  of  the  character 
of  an  acute  hyperemia,  with  extension  of  the  bloodvessels,  rupture 
of  the  walls,  and  other  characteristic  effects,  or  they  may  be  attended 
by  degeneration  of  the  neurons  with  entire  destruction  of  the  cell  and 
nerve  elements. 

Symptoms. —  General. — The  general  symptoms  are  malaise,  vertigo, 
headache,  sudden  chill,  followed  by  temperatm"e  that  may  be  as  high 
as  104°  F.,  or  somewhat  less,  with  vomiting,  convulsions,  and,  as  the 
disease  progresses,  stupor  or  coma.  The  pulse  is  rapid  but  regular, 
and  the  respiration  usually  normal.  If  death  does  not  follow  coma  and 
there  is  gradual  recovery,  there  may  be  delirium  or  actual  maniacal 
excitement. 

Lccal. — Since  lesions  of  this  character  may  aftect  different  parts 
of  the  brain,  the  s\Tnptoms  are  in  accordance  with  the  affected  area, 
and  if  the  facial  and  lingual  muscles  be  paralyzed,  as  in  acute  bulbar 
palsy,  there  will  necessarily  be  defective  speech,  difficulty  in  swallow- 
ing, and  change  in  facial  expression,  just  as  there  might  be  imbecility 
from  involvement  of  the  frontal  lobe,  strabismus,  or  paralysis  of  ocular 
movement,  if  the  oculomotor  nuclei  were  affected  and  decrease  of 
co5rdination  from  involvement  of  the  cerebellum  or  characteristic 
symptoms  from  the  spinal  cord. 

Prognosis. — The  prognosis  is  bad.  The  severity  of  the  convulsions, 
depth  of  the  coma,  degree  of  temperature,  pulse,  respiration,  and 
physical  condition  of  the  individual  are  determining  factors  in  deciding 
between  a  fatal  result  or  gradual  recovery. 


218  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Treatment. — Treatment  includes  complete  removal  and  disinfection 
or  correction  of  any  known  cause  whenever  such  treatment  may  be 
possible.  Obviously  there  should  be  careful  consideration  of  even 
remote  sources  of  local  irritation.  General  care  should  be  in  the  nature 
of  purgatives,  ice  applied  to  the  head,  antipyretics,  hot  mustard  baths 
or  hot  foot  baths,  and  similar  expedients  to  stimulate  flow  of  the  blood 
to  the  extremities. 

Cerebral  Meningitis.— Etiological  Classification.— The  several  forms 
of  this  aiTection  are  as  follows: 

Primary  Meningitis. — (1)  Epidemic  cerebrospinal  meningitis 
(spotted  fever),  due  to  the  Diplococcus  intracellularis.  (2)  Endemic 
meningitis  of  infants,  due  to  infection  by  various  microorganisms.  (3) 
Septic  meningitis  occurs  with  wounds,  fractures,  and  operations,  and 
sometimes  follows  otitis  media,  and  is  due  to  streptococcic  or  staphy- 
lococcic infection. 

Secondary  Meningitis.— This  may  result  from  pneimionia,  ulcer- 
ative endocarditis,  empyema,  typhoid  and  typhus  fever,  influenza,  the 
eruptive  fevers  of  childhood,  erysipelas,  and  other  forms  of  disease 
due  to  microorganisms.  The  most  important  forms  are:  (4)  Tuber- 
cular meningitis.     (5)   Syphilitic  meningitis: 

Meningitis  in  infants  is  of  particular  interest  to  those  whose  practice 
is  limited  to  the  operative  field  under  consideration,  and  who  do  not 
practise  general  medicine,  since  it  may  be  due  to  septic  infection 
following  disease  of  the  mouth,  nose,  and  ear,  all  of  which  are  closely 
associated  or  may  be  secondary  to  operations  in  the  region  of  the 
mouth,  throat,  and  sinuses,  because  of  the  conditions  \\-hich  are  favor- 
able to  more  direct  infection  from  these  regions.  The  syphilitic  forms 
bear  a  considerable  measure  of  diagnostic  importance  which  relates  to 
all  fields  of  practice. 

Pathology. — Cerebral  meningitis  is  marked  by  hyperemia  and 
congestion  of  the  pia  followed  by  exudation  of  serum,  IxTiiph,  fibrin, 
and  pus.  As  the  disease  extends,  the  cortex,  ventricles,  and  cranial 
nerves  become  affected,  as  does  the  cerebrospinal  fluid,  examination 
of  which  by  lumbar  puncture  makes  diagnosis  possible.  In  the 
tubercular  and  syphilitic  forms,  characteristic  evidences  may  be 
noted. 

Symptoms. — The  cranial  sjTnptoms  of  all  forms  of  meningitis  may 
be  summarized  as  follows:  Initial  chill  followed  by  high  temperature, 
usually  about  104°  to  106°  F.,  rapid  pulse,  headache,  delirium,  stupor, 
insomnia,  rigidity  and  pain  of  the  back  and  neck,  hypersensitiveness  to 
sound,  strabismus,  and  disturbance  of  vision.  Sometimes  deafness  is 
a  noticeable  sjmptom  and  facial  paralysis  very  commonly  occurs,  as 
may  also  general  convulsions.  JNIarked  restlessness,  screaming,  and 
other  evidences  of  irritability  are  sometimes  accompanied  by  champing 
movements  of  the  lower  jaws,  lips,  and  tongue.  Bulging  of  the  fon- 
tanelle  or  hydrocephalus  mav  be  apparent  in  the  long-continued  cases 
(Figs.  104  to  107). 


DISEASES  OF  THE  BRAIN 


219 


Fig.  104. — Patient  with  septic  meningitis,  subsequently  fatal;  relaxed;  comatose. 
("Brudzinski's  sign,"  after  Northrup.) 


Fig.  105. — Method  of  eliciting  the  identical  reflex,  or  neck  sign,  by  flexing  head 
on  chest.     ("Brudzinski's  sign,"  after  Northrup.) 


Fig.  106. — Method  of  eliciting  the  identical  reflex,  or  neck  sign,  by  refiexing  head, 
on  chest.     ("Brudzinski's  sign,"  after  Northrup.) 


Fig.  107. — Producing  contralateral  reflex,    or  leg  sign,  by  passive  flexion  of  one  leg, 
causing  a  reflex  flexion  of  the  other  leg.      ("Brudzinski's  sign,"  after  Northrup.) 


220  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Treatment. — In  the  cerebrospinal  form  the  antiserum  of  Flexner, 
to  be  obtained  at  the  Rockefeller  Institute  in  New  York,  seems  to 
offer  the  only  hopeful  means  of  combating  the  disease.  By  lumbar 
pimcture  15  to  30  c.c.  of  cerebrospinal  fluid  is  \\ithdrawn  and  the  same 
amount  of  antiserum  is  injected  directly  into  the  spinal  canal  slowly 
and  carefully,  in  order  to  avoid  the  production  of  symptoms  of  increased 
pressure.  This  is  repeated  at  intervals  of  three  or  four  days.  The 
septic  forms  require  the  correction  of  the  sources  of  infection  wherever 
possible,  and  with  infants  the  greatest  possible  care  should  be  taken  to 
diagnosticate  definitely  the  pathological  condition  which  has  acted  as 
a  predisposing  or  exciting  cause.  Tuberculosis  and  syphilis  require 
treatment  for  those  affections.  General  treatment  for  relief  of  the 
symptoms  and  to  assist  nature  in  combating  the  ill  effects  of  the 
disease  is  in  the  nature  of  stimulating  and  supporting  measures  to  con- 
serve and  build  up  strength  with  nourishing  food  and  the  judicious 
use  of  stimulants.  Ice-packs  to  the  head  and  spine,  and  cool  sponge 
baths,  supplemented  by  the  use  of  sedatives,  such  as  the  bromides, 
codein,  or  morphin,  if  necessary  in  small,  frequently  repeated  doses, 
may  be  employed. 

Multiple  Sclerosis. — This  disease  aflfects  both  brain  and  spinal 
cord  in  \'arying  degree,  and  is  characterized  by  small  plaques  or  eye- 
lets of  sclerotic  tissue  scattered  irregularly  through  the  central  nerve 
system. 

Etiology.^ — It  sometimes  affects  infants,  but  is  more  common  between 
the  tenth  and  thirtieth  years,  very  rarely  affecting  older  persons.  It  is 
generall}^  recognized  as  due  to  infection  from  any  of  the  various  diseases 
caused  by  microorganisms. 

Pathology. — The  sclerotic  patches  vary  from  a  millimeter  to  several 
centimeters  in  diameter.  There  may  be  hundreds  of  these  plaques  in 
the  white  matter  and  other  portions  of  the  brain  and  spinal  cord.  There 
is  production  of  a  neuroglia  structure  and  disappearance  of  the  myelin 
sheath  of  nerve  fibers. 

Symptoms. — Its  sjonptoms  are  those  that  might  be  expected  from 
lesions  which  involve  the  brain  axis  and  spinal  cord.  In  addition  to  the 
disturbance  or  loss  of  muscular  action  of  various  portions  of  the  body, 
there  is  marked  defect  in  speech,  characterized  b}^  slow,  jerky  utter- 
ance of  words,  pauses  between  words  or  syllables,  and  forced  effort 
to  pronounce.  There  may  also  be  tremor  of  the  face  and  tongue,  with 
jerky  movements  of  the  head.  In  one  type  the  bulbar  s>^nptoms 
appear  first. 

Prognosis. — It  is  claimed  that  some  patients  gradually  recover,  others 
die  within  two  years,  while  others  still  live  for  many  years. 

Treatment. — Stimulating  and  supporting  treatment,  and  that  wliich 
relieves  the  symptoms,  is  about  all  that  can  be  done  except  the  applica- 
tion of  electricity,  which  is  of  questionable  usefulness.  Its  importance 
to  our  subject  lies  in  its  recognition  in  diagnosis. 


DISEASES  OF  THE  BRAIN  221 

Abscess  of  the  Brain. — Etiology. — Injury  of  the  head  with  or  with- 
out fracture  and  particularly  septic  injection  from  compound  frac- 
tures, foreign  bodies  forced  through  the  skull,  or  other  infection  of 
any  kind  that  may  reach  the  brain  structures,  are  among  the  causes. 
Abscesses  and  necrosis  of  the  jaws,  septic  disease  of  the  sinuses  and 
middle  ear,  which  are  so  frequently  associated  in  disease,  by  reason  of 
their  direct  avenues  for  conveying  specific  and  other  infections,  have 
an  unportant  diagnostic  as  well  as  etiological  relation. 

Pathology. — Infection  by  any  of  the  pathogenic  microorganisms 
may  lead  to  a  purulent  encephalitis  with  small  localized  softened 
conditions  of  the  brain  tissue  or  larger  collections  of  pus  as  with  other 
abscesses. 

Symptoms. — The  general  symptoms  of  cerebral  abscesses  are,  in  the 
order  of  their  importance:  (1)  Headache,  general  but  sometimes 
located  over  the  seat  of  the  abscess.  (2)  A  change  in  mental  character- 
istics of  the  nature  of  irritability,  alternating  with  dulness,  imperfect 
attention,  slowness  of  thought,  and  defects  of  memory,  a  semicomatose 
condition  and  appearance  of  illness  out  of  proportion  to  the  other 
symj:)toms.  (3)  Abnormal  temperature.  (4)  Changes  in  the  blood. 
(5)  Tenderness  of  the  head  to  percussion  with  change  in  the  percussion 
note  over  the  site  of  the  abscess.  (6)  Facial  palsy  of  the  peripheral  type 
upon  the  side  affected.  (7)  Optic  neuritis.  (8)  General  febrile  symp- 
toms with  occasional  chills. 

The  development  of  these  symptoms  in  a  patient  who  has  had  an 
injury  of  the  head,  or  is  the  subject  of  chronic  otitis  media,  or  who  has 
been  exposed  to  any  of  the  causes  already  mentioned,  should  awaken 
grave  anxiety.^ 

Diagnosis. — The  diagnosis  depends  upon  the  history  of  the  injury  or 
discovery  of  the  possible  source  of  infection  and  differentiation  from 
meningitis,  thrombosis  of  the  lateral  sinuses,  and  acute  encephalitis. 

Prognosis. — The  prognosis  necessarily  depends  upon  the  possibility 
of  successfully  draining  the  abscess. 

Treatment. — Surgical  opening  of  the  abscess  cavity  and  evacuation 
of  the  pus. 

Thrombosis  of  the  Venous  Sinuses. — Thrombi  usually  form  in  the 
lateral  or  transverse  sinuses,  but  may  occur  in  any  of  the  cranial  venous 
sinuses. 

Etiology. — ^This  disease  is  caused  by  phlebitis  of  the  wall  of  the 
sinus  due  to  inflammatory  extension.  The  source  is  usually  some 
septic  process  from  the  dura  mater  or  from  otitis  media,  or  chronic 
nasal,  orbital,  or  oral  diseases.  It  may  result  secondarily  from  car- 
buncles and  abscesses  of  other  portions  of  the  body. 

Pathology. — The  thrombosis  is  usually  a  soft  clot  or  clots  adhering 
to  the  wall  of  the  sinus.  These  may  become  hard  or  organized,  or  are 
purulent  with  any  of  the  evidences  of  pus  formation. 

i  Starr:  Nervous  Diseases,  Organic  and  Functional,  4th  ed.,  p.  553. 


222  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Symptoms. — The  general  constitutional  symptoms  are  quite  similar 
to  those  of  brain  abscesses.  There  is  choked  disk  in  over  one-half 
the  cases  within  the  first  week,  especially  with  thrombus  of  the  lateral 
sinus,  which  is  the  most  frequent  through  its  close  connection  with 
the  ear.  Edema  and  swelling  with  venous  congestion  of  the  face  and 
about  the  eye,  with  other  eye  symptoms,  occur  in  thrombus  of  the 
cavernous  sinus  from  nasal  and  orbital  disease. 

Prognosis. — Absolutely  fatal,  except  when  thrombosis  of  the  lateral 
sinus  enables  operation  to  be  performed. 

Treatment. — Surgical  opening  of  the  sinus,  cleansing  of  the  clot,  and 
curettement. 

Tumors  of  the  Brain. — Brain  tumors  in  common  with  other  brain 
affections  bear  a  certain  symptomatological  relation  to  our  subject, 
chiefly  useful  in  preventing  errors  of  diagnosis  which  by  causing  delay 
might  lead  to  serious  results.  Early  differentiation  is  therefore  of  the 
first  importance. 

Pathology. — Nearly  all  varieties  of  tumors  have  been  foimd  within 
the  brain,  some  frequently,  others  more  rarely.  Tubercular  tumors 
are  by  far  the  most  common.    (See  Tumors,  page  431.) 

Symptoms. — The  general  symptoms  due  to  the  existence  of  a  new 
growth  in  the  brain  irrespective  of  its  position  are  headache,  general 
convulsions,  choked  disk,  and  optic  atrophy,  changes  of  disposition 
and  mental  power,  vomiting,  vertigo,  insomnia,  changes  in  the  pulse 
rate,  attacks  of  syncope,  polyuria,  and  progressive  malnutrition. 

Focal  symptoms  of  the  disease  in  the  cortex  of  the  brain  or  beneath 
the  cortex  in  the  projection  tracts  which  join  the  cortex  to  the  various 
subcortical  centers,  are  unilateral  spasms,  monoplegia  or  hemiplegia, 
paresthesia  or  anesthesia  in  one  or  more  limbs,  hemianopsia,  and  the 
various  forms  of  aphasia.  Affections  of  the  cranial  nerves  and  basal 
parts  of  the  brain  occur  with  tumors  in  the  basal  ganglia  and  cerebral 
axis,  or  external  to  the  brain  upon  the  base.  Symptoms  affecting  the 
twelve  cranial  nerves  necessarily  cover  a  wide  range. 

Diagnosis. — The  presence  of  any  of  the  foregoing  symptoms,  unless 
otherwise  accounted  for,  with  reasonable  certainty,  should  at  once 
demand  consultation  or  reference  to  a  neurologist  or  surgeon  of  suffi- 
cient experience  in  brain  surgery  to  prevent  the  likelihood  of  delay, 
which  might  prove  serious. 

Complete  Report  of  Case  of  Brain  Tumor. — The  following  complete 
report  of  a  case  of  brain  tumor  received  through  the  courtesy  of  Dr. 
Charles  H.  Frazier  is  included  as  a  valuable  illustration  of  symptoms 
such  as  might  be  noted  in  treatment  of  pathological  conditions  of  the 
mouth,  jaws,  and  surrounding  parts  which  would  require  distinction 
from  similar  indications  of  local  diseases.  Their  prompt  recognition 
and  early  reference  of  the  patient  to  a  brain  surgeon  would  certainly 
tend  to  increase  the  likelihood  of  avoiding  a  fatal  result: 


DISEASES  OF  THE  BRAIN  223 

Amos  Kump  (25).  University  Hospital.  No.  222.3 

Littletowu,  Peniisylvanin. 

Service  of  Dr.  Frazier.  Referred  by  Dr.  Harry  S.  Grouse. 

Admitted  March  3,  1907.  Discharged  April  12,  1907  (death). 

Diagnosis.     Brain  tumor.     Not  found. 

Operation.     Bih^teral  decompression,  April  11,  1907. 

Result.     Death. 

Chief  Complaint. 

BUndness,  intense  headache,  vomiting. 

Social  History. 

Patient  is  a  bricklayer  and  stonemason.  He  is  unmarried.  He  uses  beer  and  whisky 
sometimes  to  excess.  He  chews  tobacco  rather  freely.  He  had  specific  urethritis  about 
a  year  ago,  but  has  no  history  of  specific  infection. 

Family  History. 

Father  and  mother  both  living.  Father  has  had  St.  Vitus'  dance  for  over  forty  years. 
He  is  about  seventy  years  of  age.  Two  brothers  and  three  sisters  living  and  well.  One 
sister  died  of  eclampsia.  The  patient  says  the  members  of  his  family  are  all  more  or  less 
"nervous."  No  family  history  is  obtained  of  tuberculosis,  or  malignant,  cardiac,  or  renal 
disturbances. 

Previous  Medical  History. 

Negative,  except  that  he  has  had  a  number  of  attacks  of  tonsillitis. 

History  of  the  Present  Condition. 

The  patient  is  in  an  advanced  stage  of  mental  hebetude,  probablj'  as  a  result  of  bromism, 
and  his  statements  are  vague  and  unsatisfactory.  He  says  that  last  winter  he  began  to 
have  weakness  and  soreness  about  the  articulation  of  his  jaw.  The  soreness  afterward 
spreading  to  his  head,  where  it  has  persisted  ever  since.  About  two  months  ago  blindness 
developed  in  right  eye,  and  this  was  followed  about  two  weeks  later  by  blindness  in  the 
left  eye.  During  this  same  period  he  has  vomited  a  number  of  times.  He  is  not  able 
to  walk  about  unless  someone  leads  him.  He  believes  his  inability  to  walk  is  caused  by 
his  blindness.  His  general  health  he  believes  has  not  suffered  much.  Headache  of  late 
has  been  very  severe. 

Physical  Examination. 

A  rather  poorly  developed  and  emaciated  male  subject,  looking  considerably  older 
than  his  given  age  of  twenty-five  years.  Skin  is  covered  with  a  profuse  deeply  colored 
red  eruption,  probably  the  result  of  bromides.  No  noteworthy  glandular  enlargements. 
Pulse  is  regular,  volume  fair.  Chest  poorly  developed.  Expansion  fair  and  equal  on 
both  sides.  Heart  and  lungs  negative.  Abdomen  soft  and  symmetrical.  Abdominal 
organs  negative. 

Examination  by  Dr.  SpUler,  March  6,  1907. 

The  left  pupU  is  much  larger  than  the  right.  Both  are  immobile  to  light;  slight  con- 
traction is  obtained  in  each  pupil  in  attempt  at  convergence.  He  says  he  sees  light  with 
each  eye  separately.  He  wrinkles  the  forehead  well,  closes  the  eyelids,  shows  teeth,  and 
draws  up  each  corner  of  mouth  well;  therefore  he  has  no  involvement  of  either  facial 
nerve.  Tactile  sensation  is  completely  lost  in  the  entire  distribution  of  the  right  fifth 
nerve.  Pro\'ided  no  pressure  is  produced.  Sensation  of  pain  is  lost  in  same  distribution. 
Sensation  is  preserved  along  the  border  of  the  lower  jaw  in  the  distribution  of  the  cervical 
nerves.  Conjunctiva  and  corner  of  right  eye  are  anesthetic,  not  so  of  the  left  eye.  A 
piece  of  paper  put  far  up  the  right  nostril  is  not  felt  unless  pressure  is  produced  and 
causes  no  lacrimal  reflex.  The  jaw  is  swollen  and  uvula  is  absent.  Sensation  of  left 
nostril  is  normal.  He  is  distinctly  deaf  to  voice  in  both  ears.  The  soft  palate  moves 
very  imperfectly  on  the  right  side.  The  sense  of  smell  is  greatly  impaired  on  each  side. 
The  tongue  is  protruded  straight.  Grasp  of  each  hand  is  fair.  Upper  limbs  move  freely 
in  all  parts,  biceps  and  triceps  tendon  reflexes  not  distinct  on  either  side.  Sensation  of 
touch  and  pain  are  normal  in  each  upper  limb.  Movements  of  lower  limbs  are  free  in  all 
parts.  Patellar  tendon  reflexes  and  Achilles  tendon  reflexes  are  lost  on  each  side.  Brud- 
zinski  reflex  is  not  obtained;  toes  are  not  moved  distinctly  in  either  direction.  Sensation 
of  touch  and  pain  are  normal  in  each  limb.    Gait  and  station  are  very  ataxic;  he  has 


224  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

marked  sway  with  his  feet  close  together.  His  body  is  covered  with  eruption,  probably 
from  bromides.  Taste  for  salt  and  sugar  probably  lost  on  front  and  anterior  part  of 
tongue. 

Eye  Examination  by  Dr.  de  Schweinitz. 

Palpebral  fissures  are  about  equal  width,  left  eye  slightly  divergent.  Left  external 
rectus  movement  is  preserved.  Movement  of  internus  superior  and  inferior  rectus  is 
markedly  limited. 

Ri^ht  Eye. 

There  is  loss  of  movement  of  external  rectus  and  marked  limitations  of  movements 
of  superior  and  inferior  recti,  with  almost  lost  internal  rectus  mov^ement.  There  is  exten- 
sive double  optic  neuritis  with  large  retinal  hemorrhages  on  the  right  side. 

April  11,  1907.  Last  night  the  patient  became  unconscious;  for  the  last  few  days  he 
has  not  seemed  to  be  quite  well.  He  was  transferred  to  Dr.  Frazier's  service  for  opera- 
tion. A  lumbar  puncture  was  made,  and  the  cerebrospinal  pressure  was  found  to  be 
equal  to  27  mm.  of  mercury  (351  mm.  of  water)  and  about  5  mm.  of  mercury  (65  mm.  of 
water) . 

April  12,  1907.  A  decompressive  operation  was  done  on  each  side  of  the  head  just 
above  the  ear,  in  order  to  relieve  intracranial  pressure.  The  brain  bulged  much  on  the 
right  side.    The  patient  died  April  12,  about  2  p.m. 

April  13,  1907.  Autopsy  today  disclosed  large  tumor  of  the  left  lingual  lobe,  densely 
adherent  throughout  the  entire  right  middle  fossa  of  the  skull,  and  extending  over  the 
petrous  portion  of  the  temporal  into  the  posterior  fossa.  The  growth  appeared  to  extend 
across  the  inferior  surface  of  the  pons  and  meduUa,  involving  many  of  the  cranial  nerves. 
The  brain  tissue  of  the  temporal  lobe  was  very  much  softer  than  usual,  and  could  not  be 
removed  from  the  skull  without  being  badly  broken  up. 

Description  of  Operation  by  Dr.  Frazier. 

BUateral  decompressive  operation.  Horseshoe  cutaneous  flap,  long  incision  in  tem- 
poral muscle  and  fascia.  Crucial  incision  in  dura — not  nearly  as  much  tension  on  right 
as  on  left  side.  There  was  great  bulging  on  left  side  (which  proved  to  be  the  site  of 
tumor) . 

Diseases  of  the  Pituitary  Body. — Diseases  affecting  this  body, 
particularly  tumor  formations,  have  been  so  frequently  observed  in 
acromegaly  and  the  pituitary  extract  administered  internally  has  in 
some  cases  appeared  to  have  such  a  marked  effect  in  checking  the 
progress  of  this  affection  that  lesions  of  the  hypophysis  are  now  regarded 
as  definitely  affecting  development.  Notwithstanding  this,  Coplin 
reports  twenty-five  tumors  of  the  hypophysis  as  being  on  record  with- 
out acromegaly.  Tuberculosis  and  the  gummata  of  sj^Dhilis  and 
adenomata  are  its  most  common  affections.  Other  tumors  have  been 
reported,  but  are  somewhat  rare. 

Treatment. — As  already  stated,  the  administration  of  pituitary  ex- 
tract is  sometimes  beneficial  in  arresting  abnormal  growth.  Removal 
of  the  gland  is  required  in  cases  of  tumor  growth. 

DISEASES  OF  THE  CEREBRAL  AXIS. 

Bulbar  Palsy. — This  form  of  progressive  paralysis  affects  the  lips, 
tongue,  and  larynx. 

Etiology. — The  claims  of  authors  who  have  brought  forward  certain 
specific  causes  have  not  been  fully  accepted.  It  is  safe  to  assume, 
however,  that  it  may  result  from  any  factors  contributing  to  nerve- 
cell  degeneration  which  may  affect  the  motor  cells  of  the  medulla 
oblongata  and  pons  varolii,  such  as  the  various  intoxications,  sjq^hilis,  etc. 


DISEASES  OF  THE  CEREBRAL  AXIS 


225 


Pathology. — There  is  a  gradual  atrophy  and  degeneration  of  the 
motor  nuclei  and  nerves  of  the  medulla  oblongata  and  pons,  which 
may  or  may  not  be  accompanied  by  degeneration  of  the  pyramidal 
tracts.  There  is  usually  marked  degeneration  of  the  nerves  involved 
which  are  the  hypoglossal,  facial,  pneumogastric,  glossopharyngeal, 
vago-accessorial,  and  motor  trigeminal. 

Symptoms. — When  the  disease  affects  the  bulb  either  primarily  or 
as  an  extension  from  the  cervical  region  of  the  spinal  cord  the  clinical 
picture  is  often  described  as  "syringobulbia."  Atrophy  of  the  tongue 
and  unilateral  c  bilateral  paralysis  of  one  or  both  vocal  cords  are 
among  common  symptoms. 


Ibi^-v 


Fig.  108. — Patient  suffering  from  bulbar  par- 
alysis. Double  ptosis,  slight  external  strabismus, 
facial  paralysis,  with  lack  of  facial  expression  and 
inability  to  close  the  lips  are  to  be  seen.  The 
effort  to  open  the  eyes  causes  a  wrinkling  of  the 
forehead.      (After  Starr.) 


Fig.  109.  — ■  Bulbar  paralysis. 
Double  ptosis,  with  external  stra- 
bismus, flattening  of  the  face, 
inability  to  close  the  mouth,  and 
atrophy  of  the  right  half  of  the 
tongue  are  to  be  seen.  (Icon,  de 
la  Salpetrifere.)      (After  Starr.) 


Defective  speech  is  first  noticeable  in  an  effort  to  pronounce  such 
letters  as  d,  g,  k,  I,  r,  s,  t.  Its  tendency  is  to  progress  until  speech  is 
completely  lost.  The  constant  flow  of  saliva  from  the  mouth  is  exceed- 
ingly annoying.  Difficulty  in  swallowing  is  made  doubly  by  fluid 
passing  into  the  nose  or  larynx.  The  lips  cannot  be  contracted,  the 
voice  also  is  affected  by  paralysis  of  the  soft  palate  and  larynx,  as  is 
evidenced  by  loss  in  volume  and  change  in  tone.  Mastication  is  diffi- 
cult, due  to  the  loss  of  the  use  of  the  tongue.  There  may  or  may  not 
be  stiffness  or  weakness  of  the  muscles  of  mastication.  Usually  marked 
atrophy  of  the  lips  and  tongue  is  noticeable,  so  much  so,  that  it  is 
impossible  to  protrude  the  tongue  beyond  the  lips  and  its  tremor  is 
markedly  noticeable. 
15 


226  NERVOUS  SYSTEM  AXD  THE  BUCCAL  REGION 

Diagnosis. — Its  distinguishino;  feature  is  the  fact  that  in  addition 
to  the  symptoms  previously  described,  the  upper  part  of  the  face 
and  the  branches  of  the  facial  nerves  which  supply  the  upper  part 
of  the  face  are  apparently  normal,  and  the  affected  portion  is  limited 
to  muscles  of  the  mouth  and  chin,  the  upper  part  of  the  face  being 
quite  free.  It  is  sometimes  necessary  to  distinguish  it  from  pseudo- 
bulbar palsy,  in  which  there  is  absence  of  atrophy  and  vibratory 
tremors.  Other  brain  and  nervous  affections  causing  paralysis  are 
more  easily  excluded  (Tigs.  108  and  109). 

Prognosis.^The  termination  is  necessarily  fatal  and  may  come  in 
the  course  of  a  nimiber  of  days  or  years,  according  to  the  rapidity  of 
the  action  of  destructive  process. 

Treatment. — Treatment  is  at  best  only  palliative,  since  nothing  can 
cure  the  disease,  and  it  is  doubtful  if  efforts  to  check  its  progress  are 
effective.  To  the  oral  surgeon  its  interest  in  this  regard  comes  by 
reason  of  the  fact  that  he  will  usually  be  called  in  such  cases  in  the  hope 
that  he  may  be  able  to  relieve  the  exceedingly  distressing  salivary 
s^Tnptoms,  and  while  the  administration  of  tonics  and  spraying  the 
mouth  with  astringent  remedies  may  give  a  measure  of  temporary 
comfort,  they  cannot  be  permanently  effective. 

DISEASES  OF  THE  CRANIAL  NERVES. 

In  considering  affections  of  the  nerves  no  attempt  will  be  made  to 
include  all  of  the  pathological  conditions  which  affect  each  of  the 
twelve  cranial  nerves.  Since,  however,  the  primary  centers  of  cranial 
nerve  nuclei  are  so  closely  joined  by  associated  fibers,  and  combined 
action  is  such  a  necessary  part  of  reflex  action  concerned  in  all  such  an 
infinite  number  of  movements  and  sensations  intimately  connected 
therewith,  and  because  involvement  of  the  higher  centers  makes  up 
the  complement  of  coordination  as  affecting  the  basal  ganglia  through 
which  provision  is  made  for  automatic  acts,  it  is  evident  that  there 
must  necessarily  be  more  or  less  wide  distribution  "in  s;\Tnptoms  resulting 
from  cranial  nerve  disease,  even  though  the  actual  pathological  changes 
may  be  evidenced  in  only  one  nerve  or  in  a  distinct  region  of  nerve 
distribution.  It  therefore  becomes  necessary  for  us  to  consider  each 
nerve  through  which  pathological  states  may  be  evidenced  that  may 
affect  nerve  distribution  in  the  region  of  the  mouth,  face,  and  jaws, 
or  in  which  connection  therewith  may  be  more  indirectly  evidenced. 
Beyond  this,  however,  an  attempted  detailed  distribution  of  more 
remote  affections  would  not  only  be  inadvisable,  but  impracticable  in 
this  relation. 

LESIONS  OF  THE  FIRST  OR  OLFACTORY  NERVE. 

The  first  or  olfactory  nerve  governs  the  sense  of  smell  through  the 
specially  endowed  primary  neurons  and  finer  filaments  distributed 


LESIONS  OF  THE  SECOND  NERVE  227 

through  the  Schneiderian  membrane  of  the  nose.  It  is  particularly 
sensitive  to  any  disease  which  may  be  inflammatory  or  to  other  destruc- 
tive processes  affecting  the  mucous  membrane  of  the  nose  and  the 
nerve  filaments  it  contains. 

Anosmia  (Loss  of  smell;  perversion  of  smell). — Etiology. — Loss  or 
perversion  of  smell,  which  is  the  direct  result  of  such  disease,  may  be 
brought  about  by  nasal  catarrh,  arrest  of  nasal  secretion  when  due  to 
disease  of  the  fifth  nerve,  tumors  of  the  nose  or  polypi,  ethmoiditis  or 
disease  of  the  bones  and  cells  in  this  region,  as  well  as  meningitis,  brain 
tumors,  if  located  in  the  anterior  fossa,  and  any  disease  which  may 
destroy  or  disarrange  the  functional  activity  of  the  olfactory  bulb  or 
tract.  Occasionally  the  activity  of  this  center  is  an  evidence  of 
hysteria. 

Diagnosis. — Since  catarrhal  affections  of  the  nose  are  so  closely 
associated  with  disease  and  deformities  of  the  mouth  and  allied  affec- 
tions, as  are  also  pathological  conditions  of  the  maxillary  sinus,  through 
which  the  sphenoidal,  frontal,  and  ethmoidal  sinuses  are  so  constantly 
involved  by  extension  of  the  disease  from  one  to  the  other,  it  is  self- 
evident  that  due  consideration  must  be  given  disorders  of  the  oral 
cavity  in  considering  both  the  etiology  and  treatment  of  these  cases. 
The  loss  of  sense  of  smell  is  sometimes  a  valuable  test,  inasmuch  as  it  is 
seldom  an  evidence  of  unilateral  disease. 

Treatment. — The  treatment  concerns  the  oral  surgeon  only  insofar 
as  the  correction  of  the  oral  disease  may  be  involved,  and  for  differen- 
tiation in  the  defect  of  such  etiological  influences  as  may  require 
treatment  at  the  hands  of  rhinologists,  neurologists,  or  those  who 
follow  other  divisions  of  practice. 

LESIONS  OF  THE  SECOND  (OPTIC)  NERVE. 

Hyperemia  and  Anemia. — Hyperemia  and  anemia  of  the  optic  nerve 
are  associated  with  similar  conditions  of  the  brain.  Thrombosis  of 
the  retinal  artery  may  be  caused  by  arterial  disease  or  malarial  and 
other  poisons.  Blindness  may  result  from  either.  Each  is  usually 
associated  with  headache.  Both  are  therefore  matters  of  consideration 
in  difterential  diagnosis  when  pain  in  the  distribution  of  the  fifth  nerve 
is  a  marked  symptom. 

Edema  of  the  Optic  Nerve,  "Choked  Disk,"  "Papilledema." — 
Etiology. — Edema  occurs  from  obstruction  of  the  circulation  in  the 
eye  or  increased  intracranial  pressure,  and  is  a  common  symptom  of 
tumors,  and  occasionally  of  abscesses  of  the  brain.  It  may  cause 
impaired  vision  or  blindness,  is  usually  bilateral,  but  may  for  a  time 
aftect  one  eye.  Its  diagnostic  value  in  cases  of  brain  tiunor,  brain 
abscess,  and  intracranial  pressure  of  any  kind  is  of  the  first  impor- 
tance, and  being  associated  so  often  with  trigeminal  pain  should  always 
be  sought  for  by  proper  examination  wherever  there  is  suspicion  of 
the  existence  of  such  disease. 


228  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Optic  Neuritis. — Etiology.— Optic  neuritis  may  be  the  expression 
of  known  heredity  or  result  from  any  of  the  blood  poisons  which  are 
recognized  as  of  etiological  importance  in  other  forms  of  nem-Itis  such 
as  alcoholism,  leukocythemia,  diabetes,  and  syphilis,  or  even  rheuma- 
tism and  gout.  Direct  infection  from  brain  disease,  pressure  of  brain 
tumors  upon  the  nerve  and  other  evidences  of  intracranial  disease 
may  be  direct  causes. 

Symptoms. — Among  the  more  prominent  symptoms  are  failure  of 
sight,  objects  become  blurred,  sensitiveness  to  light,  decrease  and 
disarrangement  of  the  vision  field.  The  additional  symptoms  of  head- 
ache, vertigo,  digestive  disturbances,  nausea,  vomiting,  loss  of  strength, 
which  are  common  to  so  many  different  affections,  confuse  the  question 
of  diagnosis  and  not  infrequently  require  differentiation. 

Optic  Nerve  Atrophy. — Etiology. — Atrophy  may  result  from  any  of 
the  diseases  or  indirectly  from  all  of  the  causes  recognized  as  affecting 
brain  and  nerve  lesions. 

Symptoms. — The  symptoms  of  gradually  increasing  blindness  and 
loss  of  the  field  of  vision  may  be  associated  with  pain  in  the  eyes  and 
discomfort  after  their  use  or  exposure  to  light. 

Diagnosis. — All  the  diseases  directly  affecting  the  optic  nerve  and 
all  other  affections  of  the  eye,  whether  due  to  visual  defects,  muscular 
weakness,  overuse,  or  any  other  cause  in  which  the  symptom  of  pain 
is  a  marked  feature,  and  conjunctival  affections  which  by  any  possi- 
bility could  be  confused  with  or  induced  by  buccal  diseases,  should  be 
referred  to  a  competent  oculist.  All  attempts  at  description  of  sjonp- 
toms  which  could  by  any  possibility  lead  operators  in  other  fields  to 
attempt  eye  examination  for  the  purpose  of  differentiation  between 
the  various  pathological  optic  states  have  been  excluded  because  the 
author  is  very  firmly  of  the  belief  that  such  attempts  in  practice  are  in 
the  highest  degree  pernicious.  That  there  is  a  rapidly  developing  field 
for  useful  consultation  and  cooperation  between  the  dentist,  the  oral 
surgeon,  rhinologist,  and  the  ophthalmolgist  is  undoubtedly  true.  In 
the  author's  practice  the  valuable  assistance  of  competent  examination 
has  many  times  led  to  the  avoidance  of  great  error  in  diagnosis  and 
treatment.  On  the  other  hand,  gratifying  results  have  sometimes 
been  brought  about  by  the  correction  of  causes  of  reflex  disturbances 
from  dental  irritation  which  were  evidenced  by  pain  in  the  eye  or  eyes 
or  other  optic  disturbances  which  might  otherwise  have  been  confused 
with  the  result  of  eye-strain. 

Treatment.^ — In  the  correction  of  chronic  conjunctivitis  due  to  nasal 
disease  proper  maxillary  expansion  frequently  may  be  depended  upon 
to  open  avenues  for  proper  exit  of  secretions  and  by  improvement  in 
their  character  effectually  to  restrain  certain  forms  of  this  affection. 
It  is  confidently  believed  that  better  understanding  of  the  interrelation 
in  development  between  the  bones  of  the  head  and  face  as  influenced 
by  development  of  the  jaws,  may  in  the  future,  by  earlier  widening  of 
the  j)alate  for  correction  of  contracted  maxillse,  lead  to  more  sjinmet- 


LESIONS  OF  THE  THIRD,  FOURTH  AND  SIXTH  NERVES         229 

rical  development  of  the  orbits  in  common  Avith  other  parts,  and  in 
this  way  reduce  to  some  extent  the  frequency  of  myopia  and  presbyopia. 
In  one  case  referred  by  the  patient's  ocuhst,  beheved  to  be  marked 
strabismus  due  to  unusual  nervous  and  weak  muscular  inequality, 
markedly  increased  by  general  causes,  spreading  of  the  maxilke  and 
oral  treatment  appear  to  be  giving  valuable  assistance  at  the  present 
time  in  the  direction  of  aiding  a  girl,  aged  ten  years,  to  overcome  this 
defect  without  other  operative  assistance. 

Such  treatment  is  at  least  helpful  and  beneficial  in  a  general  way, 
even  though  not  entirely  curative. 

LESIONS  OF  THE  THIRD,  FOURTH  AND  SIXTH  NERVES. 

Paralysis  or  other  disorders  affecting  the  movement  of  the  muscles 
of  the  eye  and  eyelid  bear  a  considerable  measure  of  diagnostic  impor- 
tance in  the  distingyishment  of  nervous  disorders  affecting  the  mouth 
or  other  portions  of  the  face  and  jaws,  for  the  reason  that  factors  which 
are  responsible  for  the  causation  of  diseases  of  oral  nerves  are  identical 
with  those  which  lead  to  other  brain  and  nerve  affections.  Because 
the  sympathetic  fibers  of  the  third  nerve,  which  leave  the  spinal  cord  in 
the  first  dorsal  nerve  root,  pass  to  the  superior  cervical  ganglion  and 
from  the  cavernous  plexus  to  the  Gasserian  ganglion  of  the  fifth  nerve, 
and  with  the  first  branch  of  the  fifth  to  the  iris;  there  is  also  much  in 
common  between  these  nerves  as  evidencing  pathological  influences 
upon  either  or  both.  Quite  frequently  the  presence  or  absence  of  loss  of 
motion  in  the  region  of  the  eye  serves  to  point  the  way  to  differentia- 
tion between  central  and  peripheral  locations  of  first  causes  in  nerve 
disease.  Therefore  s\inptoms  of  ptosis,  or  falling  of  the  upper  eyelid, 
dilatation  of  the  pupil  and  loss  of  reflex  action  to  light  and  accommoda- 
tion, turning  of  the  eyeball  outward  and  slightly  upward,  which  are 
indications  of  third  nerve  'paralysis,  may  call  for  careful  oral  examina- 
tion in  at  least  a  supplementary  way  or  be  of  value  in  preventing 
attempted  local  care  of  central  disease. 

Fatheticus  Paralysis. — Patheticus  paralysis  is  a  rare  affection  due 
to  paralysis  of  the  fourth  nerve.  It  causes  double  images.  When 
isolated,  paralysis  of  the  fourth  nerve  exists  without  affection  of  the 
third  or  sixth  nerves.  It  is  an  important  symptom  of  tumor  of  the 
cerebellum. 

Paralysis  of  the  Sixth  Nerve. — Abducens  Paralysis. — Paralysis 
of  the  sixth  nerve  is  a  frequent  evidence  of  intracranial  disease.  Its 
characteristic  symptom  is  internal  strabismus,  or  turning  of  the  e^^e 
inward,  with  inability  to  turn  the  eye  outward,  due  to  paralysis  of  the 
external  rectus  muscles.  This  nerve  supplies  the  unopposed  contraction 
of  the  internal  rectus.  It  is  accompanied  b}'  double  vision  and  may  also 
be  associated  with  various  forms  of  ocular  palsy.  The  cranial  course 
of  the  sixth  nerve  is  so  long  that  it  is  likely  to  be  affected  by  disease  at 
any  part  at  the  base  of  the  brain.    Its  symptoms  therefore  require  due 


230  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

consideration  in  the  diagnosis  of  many  pathological  conditions  pertain- 
ing to  both  fifth  and  seventh  nerves  as  well  as  affections  of  the  third  or 
sixth  and  in  cases  of  brain  tumors. 

Symptoms. — Acute  ophthalmoplegia,  a  disease  of  the  nuclei  of  the 
nerves  that  supply  the  muscles  of  the  eyeball  and  causes  their  paralysis 
usually  begins  suddenly  with  severe  cerebral  symptoms,  vertigo, 
vomiting,  headache,  and  sometimes  delirium  and  coma,  accompanied 
by  paralysis  affecting  the  action  of  the  pupil  or  of  motion  of  the  eye- 
balls when  the  levator  palpebrae  are  affected.  (Ophthalmoplegia 
externa.  Fig.  110.) 


Fig.  110. — Patient  suffering  from  chronic  ophthalmoplegia  externa.  The  wrinkling 
of  the  forehead  in  the  effort  to  open  the  eyes  is  noticeable.  The  external  strabismus 
can  be  seen.     (After  Starr.) 

Prognosis. — In  all  forms  of  paralysis  of  the  eye  muscles  when  symp- 
toms of  bulbar  paralysis  develop  the  result  is  usually  fatal.  Otherwise 
there  may  be  relief  in  the  course  of  one  or  two  weeks,  or  a  chronic, 
slightly  improving  paralysis  extending  over  a  period  of  years.  In  the 
chronic  form  there  may  be  gradual  development  of  bulbar  palsy,  or 
extension  of  paralysis  to  other  regions,  or  recovery  in  the  large  majority 
of  cases  if  the  ophthalmoplegia  is  only  partial. 

Treatment. — The  treatment  of  lesions  of  the  third,  fourth,  and  sixth 
nerves  properly  belong  with  other  fields  of  practice,  except  insofar  as 
the  oral  surgeon  may  be  able  to  contribute  to  general  healthfulness 
or  to  the  relief  of  local  irritations  which  may  tend  to  aggravate  the 
condition. 

DISEASES  OF  THE  FIFTH  OR  TRIGEMINAL  NERVE. 

General  Consideration. — In  order  to  facilitate  better  understanding 
of  each  of  the  many  diseases  of  this  nerve,  those  affecting  its  principal 


DISEASES  OF  THE  FIFTH  OR  TRIGEMINAL  NERVE 


231 


divisions  are  separately  described,  but  it  must  be  remembered  that 
since  both  motor  and  sensory  portions  of  the  nerve  are  so  commonly 


Fig.  111. — Scheme  of  the  neurons  making  up  the  fifth  or  trigeminal  nerve.     (Edingor, 

after  Starr.) 


232  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

in^■olved,  especially  ^^•he^  the  Gasserian  ganglion  is  affected,  an  exact 
division  of  pathological  evidences  of  disease  is  impossible.  Quite 
commonly  spasmodic  contractiun  of  the  muscles  is  associated  with  pain. 
In  like  manner,  trophic  disturbances  may  be  evidence  of  disease  affecting 
either  or  both  divisions.  The  same  is  true  of  irritations,  such  as  herpes, 
acne,  or  eczema,  flushing  or  paling  of  the  skin,  alteration  of  tempera- 
ture and  appearance  of  the  skin  surface,  unusual  activity  of  the  sweat 
glands,  atrophy,  or  altered  development.  Consideration  of  the  causes 
and  treatment  of  these  affections  is  necessarily  a  part  of  the  descrip- 
tion of  the  diseased  conditions  with  which  they  are  associated  (Fig.  111). 

Degeneration.^!) egeneration  takes  place  in  this  as  in  other  nerves 
and  nerve  structures,  and  the  same  general  or  local  causes  come  into 
consideration.  As  a  result  of  injury  there  may  be  compression  without 
rupture  of  the  sheath  of  Schwann,  which  dri\es  the  myelin  away  from 
the  point  of  pressure  and  causes  degeneration  of  the  axis-cylinder,  or 
with  the  sheath  of  Schwann  ruptured,  exudation  of  the  myelin  occurs 
with  consequent  degeneration  of  the  axis-cylinder.  Following  these 
changes  there  is  an  increase  of  nuclei  and  connective-tissue  fibrils, 
with  tendency  to  transformation  of  the  nerve  into  connective  tissue. 
At  the  point  of  division  a  bulbous  growth  of  connective  tissue  forms  a 
sensitive  scar. 

Nerve  Regeneration. — Xerve  regeneration  is  important  in  its  bearing 
upon  the  continuance  of  relief  from  operations  for  tic  douloureux, 
and  the  possibility  of  surgical  anastomosis  or  spontaneous  correction 
of  results  from  disease  or  injury.  Clinically,  it  is  well  known  that  some 
sort  of  regenerative  process  does  take  place  when  ner^-es  are  severed. 
Whether  it  is  by  a  continued  growth  and  extension  of  the  ner^•e  fibers 
from  the  central  portion  as  claimed  by  Ranvier  and  others,  or  because 
protoplasm  with  specific  developmental  properties  forms  and  unites 
the  elements  of  the  new  fiber  to  the  old  one,  as  claimed  by  Neumann, 
may  be  a  matter  of  question.  Bowlby,^  however,  found  regenerating 
nerves  in  the  peripheral  portion  in  three  cases  some  months  after  opera- 
tion, and  the  quite  common  practice  of  surgical  anastomosis  of  nerves 
with  strands  of  catgut,  with  favorable  results,  demonstrates  the  clinical 
possibilities  of  regenerative  processes. 

AFFECTIONS  OF  THE  MOTOR  PORTION  OF  THE  FIFTH  OR 
TRIGEMINAL  NERVE. 

Paralysis. — Injury  or  disease  of  the  motor  portion  of  the  trigeminal 
nerve  is  evidenced  by  paralysis  of  the  muscles  of  mastication.  The 
lower  jaw  falls  open  and  the  acts  of  swallowing  or  speech  become 
difficult  or  impossible.  Unless,  however,  both  sides  are  affected,  there 
will  be  sufficient  activity  of  the  muscles  upon  the  opposite  side  to  pre- 
vent complete  loss  of  action. 

1  Starr:  Nervous  Diseases,  Organic  and  Functional,  4th  cd.,  p.  165;  Injury  of  Nerves, 
p.  25. 


AFFECTIONS  OF  THE  FIFTH  OR  TRIGEMINAL  NERVE       233 

Deafness  and  tinnitus  aurium  (page  300)  may  result  when  the  small 
branch  of  the  motor  portion  which  passes  to  the  tensor  tympani  from 
the  otic  ganglion  is  paralyzed,  because  tightening  of  the  ear-drum  is 
thus  prevented.  Paralysis  of  the  sphenostapedius  muscle  may  cause 
a  slight  difficidty  in  swallowing,  with  deviation  of  the  uvula  toward 
the  i)aralyzed  side,  due  to  paralysis  of  the  muscles  about  the  hard 
palate,  through  paralysis  of  this  muscle,  which  is  connected  with  the 
motor  branch  of  the  trigeminal  nerve.  These  symptoms  follow  division 
of  the  motor  branch  when  this  occurs  in  operation  for  trigeminal 
neuralgia  (page  258),  and  as  a  matter  of  course  the  motor  branch 
should  be  avoided  if  possible  (Fig.  114). 


Fig.  112. — Hemiatrophy    of    the    face.  Fig.  113. — Hemiatrophy   of   the  face. 

The  condition  had  developed  in  two  years.  The   condition   developed   slowly   during 

(After  Starr.)  five  years,  and  then  came  to  a  stand-still 

at  the  point  shown.     (After  Starr.) 


Hemiatrophy  of  the  Face.— Paralysis  of  the  muscles  which  depend 
upon  this  nerve  for  motor  activity  sometimes  leads  to  a  gradual  facial 
atrophy,  and  through  the  effect  of  muscle  degeneration  causes  gradual 
sinking  in  of  the  facial  features  upon  the  affected  side.  This  is  differen- 
tiated from  true  facial  hemiatrophy,  because  in  the  latter  the  muscles 
are  not  paralyzed  and  there  is  no  marked  loss  of  sensation,  although 
there  is  a  slowly  progressive  atrophy  which  affects  all  of  the  tissues, 
including  skin,  fat,  muscles,  and  bones.  This  affection  is  rare,  and  its 
pathology  practically  unknowTi.  It  usually  appears  before  the  age  of 
ten  years,  and  rarely  after  twenty.  The  general  effect  is  asymmetry  of 
the  face,  which  gradually  becomes  more  and  more  e^•ident  until  in 
natural  course  its  progress  ceases.  A  fatal  termination  does  not  result, 
and  it  therefore  is  distinguishable  from  muscular  dystrophy,  which  has 
a  tendency  to  fatal  termination,  and  because  there  is  no  associated 


234 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


muscular  paralysis.     It  seems  reasonable,  however,  to  suppose  that 
there  is  some  analogy  between  the  etiological  factors  which  act  as 


■"•*?is-vi,w 


Fig.  114.— Showing  the  distribution  of  the  fifth,  seventh,  and  eleventh  cranial  nerves 
and  the  cervical  and  brachial  plexuses;  also  the  area  of  the  middle  meningeal  artery  in 
the  inner  table  of  the  skull,  injury  to  which  is  sometimes  the  cause  of  hemiplegia;  also 
the  course  of  the  bloodvessels  in  the  neck  and  face.     (Arnold's  Atlas.) 


predisposing  or  exciting  causes  in  the  several  forms  of  facial  atrophy 
(Figs.  112  and  113). 


AFFECTIONS  OF  THE  FIFTH  NERVE  235 

HABIT  AND  OTHER  SPASMODIC  AFFECTIONS  OF  THE  MUSCLES 
SUPPLIED  BY  THE  MOTOR  DIVISION  OF  THE  FIFTH  NERVE. 

Spasm  of  Muscles  of  Mastication. — Trismus,  or  tonic  spasm  of  the 
muscles  of  mastication,  is  usually  associated  with  general  convulsions 
or  tetanus  (page  90),  and  in  these  cases  is  not  properly  a  local  disease 
of  the  motor  branch  of  the  fifth  nerve.  Spasmodic  affections  of  the 
muscles  of  mastication  which  occur  in  connection  with  facial  or  other 
spasms  are  also  to  be  excluded  for  the  same  reason  (page  309). 

Etiology. — Direct  irritation  of  the  trigeminal  nerve  from  impacted 
third  molars  and  other  teeth  is  quite  a  common  cause  of  tonic  spasm 
of  the  masse ters.  These  and  other  causes,  such  as  long-continued 
dental  operations,  irritation  from  inflammatory  conditions,  results  of 
paralysis,  hysteria,  etc.,  are  treated  more  at  length  (page  309).  Clonic 
spasm  of  the  muscles  of  mastication  occurs  in  many  different  forms  in 
greatly  varying  degrees  and  from  widely  different  causes.  It  may  be 
evidenced  by  chattering  of  the  teeth  during  chills  or  fear,  or  be  a  symp- 
tom of  paralysis  agitans.  Grinding  the  teeth,  particularly  at  night, 
is  a  well-known  symptom  of  many  affections  of  childhood,  which 
directly  or  indirectly  disturb  the  nervous  system,  such  as  intestinal 
irritations  from  worms,  indigestion  or  similar  affections,  adenoids  and 
enlarged  tonsils,  irritating  conditions  of  the  eye  or  ear,  or  of  the  genitals, 
or  any  similar  form  of  reflex  irritation,  and  particularly  pathological 
dentition  (page  59).  It  is  sometimes  a  sign  of  irritation  at  the  base  of 
the  brain,  and  notes  the  beginning  of  tubercular  meningitis.  Tumors 
at  the  base  of  the  brain  or  any  of  a  variety  of  diseases  may  be  so  slight 
as  to  be  safely  outgrown  or  lead  on  to  serious  or  fatal  termination. 
In  adults  the  habit  of  tooth  grinding  is  an  important  factor  from  both 
causative  and  complicating  aspects  in  many  nervous  affections  (page 
280).  It  is  also  important  when  concerned  in  habits  of  biting  the 
cheeks  or  lips  as  leading  to  possible  degenerative  changes  in  the  tissues 
subject  to  these  chronic  irritations. 

Herpes  Zoster. — Herpes  zoster  upon  the  face  is  sometimes  associated 
with  congenital  paralysis  of  the  trigeminal,  and  may  result  from  dis- 
eased conditions  of  the  Gasserian  ganglion,  injury  of  the  fifth  nerve, 
or  pressure  upon  the  base  of  the  brain  by  tumors.  Syphilitic 
or  tubercular  exudation  in  the  meninges  may  be  associated  with 
symptoms  of  the  bulbar  paralysis  of  syringomyelia,  as  described  on 
page  198. 

Treatment. — The  treatment  of  the  foregoing  diseases  affecting  the 
motor  branch  of  the  fifth  nerve,  insofar  as  they  may  be  amenable  to 
therapeutic  measures,  depends  chiefly  upon  a  diagnosis  which  will 
lead  to  discovery  of  the  cause  and  to  correction.  Aside  from  the 
general  upbuilding  which  all  such  patients  require,  remedial  efforts 
must  be  directed  to  relief  of  the  causative  factor,  and  such  hope  of 
improvement  as  there  may  be  necessarily  depends  upon  the  possibility 
of  successful  accomplishment  in  this  direction.     General  treatment 


236  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

must  be  given  for  causative  or  complicating  constitutional  pathological 
states,  and  this  supplemented  by  hygienic  care,  electricity,  massage, 
or  other  efforts  to  bring  about  improvement  of  nervous  conditions. 
Chief  dependence  must  be  placed  upon  diagnosis  and  the  treatment  of 
local  affections  which  may  cause  peripheral  irritation  in  the  distribu- 
tion of  the  nerve.  These  are  identical  with  those  which  cause  other 
forms  of  disturbance,  and  are  grouped  and  considered  on  pages  280 
to  289. 

AFFECTIONS  OF  THE  SENSORY  PORTION  OF  THE  FIFTH 
OR  TRIGEMINAL  NERVE. 

Hyperesthesia. — Hyperesthesia  consists  in  excessive  sensibility  or 
impressibility,  Hyperesthetic  areas  of  skin  surface,  exceedingly  pain- 
ful to  touch,  are  quite  frequently  associated  with  trigeminal  neuralgia. 
Among  the  author's  patients,  persons  of  otherwise  cleanly  habits  have 
been  unable  to  wash  their  faces  for  weeks  or  months  because  of  the 
painful  sensation  this  excited. 

Paresthesia. — Paresthesia  is  characterized  by  a  tingling  and  numb- 
ness of  the  skin  and  mucous  membrane  felt  in  the  distribution  of  the 
sensory  filaments  of  the  nerve.  Such  sensations  are  usually  felt  in  the 
extremities,  but  are  not  infrequent  in  certain  portions  of  the  mouth, 
particularly  along  the  side  of  the  tongue. 

Etiology. — Numbness  of  this  character  in  the  extremities,  as,  for 
example,  when  the  foot  or  hand  is  said  to  be  asleep,  is  caused  by  pres- 
sure upon  the  nerves  during  sleep  or  otherwise,  and  may  be  a  first 
symptom  of  the  onset  of  some  more  serious  affection.  In  the  distribu- 
tion of  the  fifth  nerve  the  cause  is  frequently  irritation  from  dental 
pulps  or  pericemental  inflammation  due  to  malocclusion,  jaw-biting 
habits,  and  similar  affections. 

Pathology. — There  is  slight  mipairment  of  nutrition  in  the  nerve 
caused  by  venous  congestion. 

Symptoms. — ^The  nimibness  may  be  of  transitory  nature,  may  last 
for  short  periods  but  recur  frequently,  or  may  be  almost  continuous 
and  in  time  lead  on  to  true  neuritis. 

Treatment, — ^The  treatment  consists  in  relief  of  the  local  irritation 
whenever  such  cause  may  be  discovered.  The  author  believes  par- 
esthesia to  be  a  much  more  important  symptom  in  the  fifth  nerve  dis- 
tribution than  is  usually  understood.  In  a  considerable  number  of  his 
cases  it  has  been  found  to  be  a  first  indication  of  reflex  irritation  from 
dental  pulp  disease,  or  tooth-crowns  that  have  been  inserted  injudi- 
ciously or  unskilfully  without  due  regard  for  occlusion.  For  example,  a 
young  woman,  aged  about  thhty  years,  a  seamstress,  was  so  troubled 
by  numbness  along  the  side  of  her  tongue  that  it  began  to  prey  upon  her 
mind  until  it  became  a  very  important  irritating  factor  in  connection 
with  a  condition  of  general  nervous  debility  with  symptoms  of  neuras- 
thenia.   Examination  disclosed  a  piece  of  bridge-work  that  had  been 


AFFECTIONS  OF  THE  FIFTH  NERVE  237 

inserted  by  a  dentist  some  months  before,  upon  which  were  bright 
worn  s])ots  upon  the  occlusal  surfaces,  such  as  in  gold  crowns,  bridges, 
and  fillings  always  indicate  malocclusion  and  the  results  of  tooth- 
grinding.  The  removal  of  this  bridge-work  and  treatment  of  the  pulp 
of  a  molar  tooth  that  had  been  crowned  by  one  of  the  gold  caps  gave 
relief  from  the  distressing  symi)toms,  and  this,  supplemented  by  tonics 
and  good  general  care,  brought  about  a  restored  condition  of  health 
with  marked  increase  in  weight.  After  a  period  of  rest  an  attempt  was 
made  to  restore  the  bridge-work  in  the  belief  that  it  might  then  be 
safely  tolerated  in  the  mouth,  but  a  prompt  recurrence  of  the  numb 
sensation  in  the  tongue  made  removal  necessary. 

Anesthesia. — Paralysis  of  the  sensory  portion  of  the  fifth  or  trigeminal 
nerve. 

Etiology. — It  may  be  due  to  any  pathological  condition  involving 
the  Gasserian  ganglion  or  one  or  more  branches  of  the  nerve,  operations 
upon  the  Gasserian  ganglion  and  resections  and  other  operative  pro- 
cedures upon  the  nerve,  tramnatic  injury  to  the  nerve  structures, 
laceration  incident  to  the  removal  of  impacted  third  molars  or  other 
teeth,  resections  of  the  jaws,  removal  of  large  sequestra  of  necrosed 
bone  containing  more  or  less  important  branches  of  the  nerve  and 
similar  conditions. 

Symptoms. — ^The  symptoms  include  nmubness  and  anesthesia  of 
the  parts  supplied  by  the  nerve,  including  mucous  membrane  surfaces. 
This  numbness  is  sometimes  accompanied  by  a  prickling  sensation 
which  is  occasionally  very  distressing  to  the  patient.  Food  collects 
between  the  teeth  and  cheeks.  The  facial  muscles  are  affected  in  their 
normal  activity  through  loss  of  muscle-sense  by  reason  of  the  lack  of 
normal  sensory  stimulation  and  the  guidance  which  sensation  gives. 
Occasionally  this  is  so  great  as  to  simulate  Bell's  palsy.  In  the  graver 
cases  there  may  be  increase  or  decrease  in  the  flow  of  saliva,  tears, 
nasal  and  oral  mucus.  These  alterations  sometimes  lead  to  secondary 
ill  effects,  such  as  impairment  or  loss  of  sense  of  smell  through  change 
in  the  Schneiderian  membrane.  Ophthalmic  changes  may  occur  in  a 
similar  way.  Among  these  symptoms  a  distressing  feature  is  altera- 
tion of  the  sense  of  taste  which  is  lost  or  at  least  seriously  impaired 
over  the  anterior  two-thirds  of  the  tongue  and  to  some  extent  at  the 
posterior  portion  of  the  tongue.  The  glossopharyngeal  nerve  is  credited 
with  supplying  gustatory  sensation  to  the  posterior  portion  of  the 
tongue,  and  the  chorda  tympani  to  the  anterior  two-thirds,  but  the 
connection  between  the  chorda  tympani  and  the  brain  as  to  whether 
it  passes  by  way  of  the  trigeminus  or  by  the  facial  or  glossopharyngeal 
arch  is  still  unsettled.  Evidence  favoring  both  theories  has  been  pre- 
sented by  many  authors  in  observation  of  results  of  operations  on  the 
Gasserian  ganglion,  lesions  involving  the  facial  nerve,  and  the  pars 
intermedia  between  the  geniculate  ganglion  and  the  pons.  Gushing 
has  reported  13  cases  of  total  extirpation  of  the  ganglion  with  only  1 
in  which  taste  perception  failed  to  be  reestablished,  and  in  this  case  the 


238  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

chorda  tyinpani  had  been  divided  at  a  previous  operation.  Thus  it 
would  appear  that  the  taste  fibers  do  not  pass  exclusively  by  way  of 
the  trigeminal  nerve  to  the  brain.  The  opposite  view  is,  that  the  fibers 
of  the  chorda  tympani  pass  through  the  geniculate  ganglion  by  way 
of  the  pars  intermedia  to  the  brain  in  association  with  the  facial  nerve, 
but  it  is  a  notable  fact  that  lesions  of  the  facial  nerve  involving  the  pars 
intermedia  do  not  usually  affect  the  sense  of  taste.  Therefore  it  seems 
fair  to  conclude  that  there  are  individual  differences  and  that  the  taste 
fibers  do  not  reach  the  brain  in  the  same  way  in  all  persons.  From  a 
surgical  point  of  view  this  is  undoubtedly  the  safer  ground  to  take. 

Pain. — Pain  occurs  in  a  great  variety  of  forms  and  may  be  at  the 
point  of  injury  or  include  all  of  the  distal  portion  of  the  affected  division 
of  the  nerve.  It  may  also  be  reflected  to  other  divisions  and  manifest 
itself  at  some  point  quite  distant  from  the  actual  lesion  or  source  of 
irritation. 

Headache. — Pain  in  the  head  is  caused  by  disturbance  of  nutrition 
of  the  brain,  and  may  be  a  notable  feature  of  syphilitic  meningitis  and 
other  diseases  of  the  brain  structures  and  nerves,  as  well  as  of  many 
other  general  conditions.  The  character,  form,  period  of  continuance, 
and  treatment  of  such  headache  is  necessarily  governed  by  the  disease 
of  which  it  is  a  symptom. 

Symptoms. — It  may  be  sudden,  sharp,  and  excruciating,  and  of  short 
duration,  or  continue  for  hours,  or  may  appear  in  many  other  forms. 
It  is  distinguished  from  the  pain  of  neuralgia  because  it  is  not  limited 
to  a  particular  nerve  trunk,  and  from  migraine,  as  usually  considered, 
because  it  is  not  unilateral  and  does  not  occur  periodically. 

Migraine. — Migraine  or  periodical  headache,  according  to  Starr, 
Dunglison,  and  many  others,  is  considered  as  identical  with  hemi- 
crania  or  periodical  unilateral  pain  in  the  head.  Jellift'e,^  however, 
describes  it  with  certain  reservations  as  follows:  "Migraine  may  be 
defined  as  a  periodical  abnormal  state  in  which  the  patient  suffers 
from  a  peculiar  oppressive  pain  in  the  head,  unilateral  or  bilateral, 
localized  or  general,  which  develops  very  gradually  from  heaviness  or 
dulness,  to  pain  that  is  splitting."  The  tendency  of  the  modern  writers 
is  to  discard  the  unilateral  feature  and  consider  it  as  an  affection  which 
may  be  unilateral  or  bilateral.  Usually  with  these  attacks  there  are 
certain  symptoms  which  have  given  rise  to  the  use  of  the  term  "  oph- 
thalmic migraine,"  a  form  of  nervous  disturbance  accompanied  by 
headache  and  associated  with  disordered  vision. 

Etiology. — Heredity  bears  an  important  relation  to  this  affection 
and  is  one  of  the  most  common  predisposing  influences,  the  family 
history  showing  other  members  to  have  been  affected.  It  rarely  affects 
infants,  but  sometimes  begins  at  about  seven  to  nine  years  of  age, 
though  it  usually  occurs  at  puberty.  Faulty  metabolism,  whether  due 
to  some  congenital  defect  in  the  chemistry  of  nutrition  or  to  an  acquired 

'  Osier:  Modern  Medicine,  2d  ed.,  vol.  v,  1915. 


AFFECTIONS  OF  THE  FIFTH  NERVE  239 

derangement  of  metabolic  processes,  is  undoubtedly  the  principal 
cause,  and,  as  might  be  expected,  disturbance  of  digestion,  autotoxemia, 
gout,  arthritis,  and  similar  factors  with  varying  degrees  of  importance, 
as  anemia,  want  of  outdoor  exercise,  sedentary  habits,  indoor,  confining, 
nerve-exhausting,  eye-straining,  and  otherwise  trying  occupations  are 
contributing  elements. 

Visual  Defects. — Walton^  considers  it  to  be  an  occupation  neurosis, 
resulting  in  individuals  of  neurotic  inheritance  from  overuse  under 
the  handicap  of  refractive  error  of  the  parts  concerned  in  vision, 
Gradle-  does  not  agree  with  this.  He  holds  that  sometimes  refractive 
error  is  of  vital  importance  in  these  cases  and  sometimes  it  is  not,  and 
gives  the  following  results  in  treatment  of  90  cases  which  are  extremely 
instructive:  22  practically  cured  by  glasses;  22  benefited  by  glasses; 
31  not  benefited  by  glasses;  15  not  requiring  glasses  (except  simple 
convex  spheres). 

There  is  quite  commonly  a  premonitory  sensation  of  scotomata, 
which  has  been  likened  to  the  aura  of  epilepsy,  and  for  this  reason 
migraine  has  been  classed  as  of  "epileptic  character"  by  some  authors, 
but  this  view  in  its  full  sense  is  not  generally  accepted,  the  chief  argu- 
ment being  such  large  numbers  of  people  are  afi^ected  in  whom  there  is 
no  evidence  of  epileptic  tendency. 

Symptoms. — The  attack  may  be  ushered  in  by  certain  premonitory 
symptoms,  such  as  scotomata  and  other  visual  signs.  There  may  be 
partial  blindness,  temporary  aphasia,  numbness,  loss  of  memory, 
dulness  of  mental  activity,  a  sense  of  chilliness,  nausea,  tinnitus  aurium, 
modifications  of  taste,  smell,  or  touch,  and  a  peculiar  oppressive  pain 
in  the  head  which  may  be  localized  or  general,  developing  from  dulness 
until  it  may  become  intensely  severe.  The  frontal  and  temporal  regions 
are  most  often  involved,  the  occipital  next,  and  the  vertex  seldom  ever 
alone.  During  the  attacks  the  patients  are  somnolent  and  sleep  for 
hours  and  even  days.  Attacks  may  occur  biweekly  or  within  intervals 
of  only  a  few  days,  monthly,  as  with  many  women,  or  at  longer  intervals. 

Diagnosis. — ^The  history  of  the  case  may  usually  be  depended  upon 
for  differentiation  from  other  forms  of  headache,  the  ophthalmic  and 
other  sensory  symptoms  distinguish  it  from  the  different  forms  of 
trigeminal  neuralgia. 

Prognosis. — The  probability  of  complete  relief  is  small;  the  frequency 
and  severity  of  attacks  may  usually  be  benefited  by  change  of  habits 
of  life  and  treatment.  Usually  the  attacks  subside  at  about  the  age  of 
fifty,  after  the  menopause  in  women,  and  sometimes  after  ovariotomy. 

Treatment.- — Regulation  of  diet  is  a  matter  of  first  importance. 
Good  hygienic  care,  including  exercise,  baths,  and  proper  massage, 
with  lots  of  good  air  and  outdoor  exercise,  are  also  helpful.  There 
should  be  thorough  cleansing  of  the  bowels,  and  in  anemic  patients 
ovoferrin  or  some  similar  preparation  to  improve  the  red  blood  cor- 

1  Jour.  Am.  Med.  Assn..  June,  1908,  p.  202.  ^  jbid. 


240  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

puscles  or  tonics  should  be  given.  Washing  the  stomach  with  some 
alkaline  solution  is  recommended  to  abort  attacks.  For  the  relief  of 
pain,  heat  should  be  applied  to  the  feet  and  ice-packs  to  the  head;  a 
soothing  rubbing  which  will  tend  to  carry  the  blood  toward  the  extremi- 
ties and  the  use  of  antipyretics  are  indicated.  Morphin  by  hypodermic 
will  of  course  give  relief,  but  is  to  be  avoided  if  possible  because  of  the 
danger  of  acquiring  the  habit.  For  the  relief  of  the  s>aiiptom  of  tooth- 
grinding  and  the  incidental  irritation  with  consequent  increase  of  pain, 
an  appliance  devised  by  the  author,  and  called  a  "soft-rubber  bit," 
has  given  much  relief  and  assisted  in  overcoming  the  habit  in  many 
cases.    This  appliance  is  illustrated  and  described  on  page  291. 

NEURALGIA. 

Trigeminal  Neuralgia. — Neuralgia  is  a  disease  of  a  sensory  nerve 
characterized  by  pain  in  the  course  of  the  nerve  or  in  its  peripheral 
distribution.^ 

The  trigeminal  nerve  is  distributed  over  a  wide  area,  and  the  bony 
canals  through  which  its  several  branches  pass  expose  it  to  injury  not 
only  in  the  terminal  ends  of  the  nerve  itself,  but  there  is  also  the  likeli- 
hood of  fractiu-e,  compression,  or  maldevelopment  of  surrounding  bone 
structures.  It  is  in  close  association  with  other  cranial  nerves  through 
which  it  may  become  affected.  The  twenty- two  teeth  of  the  deciduous 
set,  and  the  thirty-two  of  the  permanent,  which  are  supplied  by  its 
branches,  all  have  pulps  and  surrounding  pericemental  structures  which 
are  quite  commonly  diseased  and  therefore  frequent  sources  of  irritation. 
For  these  reasons  this  nerve,  as  might  be  expected,  is  the  one  most 
frequently  affected  by  neuralgia.  The  affection  occurs  more  often  in 
women  than  in  men.  It  may  begin  at  almost  any  period  of  life,  but  is 
more  frequent  in  its  serious  aspects  in  middle  or  later  life. 

Classification. — The  types  of  this  affection  classified  in  accordance 
with  its  clinical  aspect  are : 

Neuralgia  Minor. — This,  as  its  name  implies,  represents  the  less 
severe  forms,  and  may  usually  be  described  with  the  name  of  the 
affected  branches  of  the  nerve. 

Visceral  Referred  Pain,  Ueflex,  or  SymiJtomatic  Neuralgia. — The 
irritation,  of  which  the  reaction  of  the  nerve  system  is  an  expression, 
may  be  referred  from  the  teeth,  the  eye,  ear,  nose,  tongue,  and  other 
organs  associated  in  the  fifth  nerve  distribution. 

Neuralgia  Major;  Tic  Doulonreux;  Ejnleptiform  Neuralgia. — ^This  is 
the  generic  term  for  a  very  acute,  exacerbating,  or  intermitting,  throb- 
bing pain,  which  follows  the  course  of  a  nerve,  extends  to  its  ramifica- 
cations,  and  seems,  therefore,  to  be  seated  in  the  nerve. 

The  terms  symptomatic  and  idiopathic,  as  sometimes  used  in  classifi- 
cation by  grouping  under  the  former  term  the  two  first  types  and  the 

1  Starr:  Nervous  Diseases,  Organic  and  Functional,  4th  cd.,  p.  729. 


NEURALGIA  241 

third  iiiuler  the  hitter,  appear  to  be  too  indefinite  and  not  quite  in 
acconhincc  with  recent  advances  in  the  study  of  the  pathology  of  tic 
douloureux. 

Etiology. — -The  factors  which  may  be  concerned  in  causing  the  various 
forms  of  trigeminal  neuralgia  are  so  numerous,  their  character  is  so 
widely  different,  and  their  importance  in  directing  methods  of  treat- 
ment so  great  that  division  into  groups  according  to  pathological 
similarity  is  necessary. 

The  follo^dng  classification  of  causes  is  a  modification  of  one  first 
suggested  by  Wm.  Rose  and  quoted  by  ^Murphy  and  XeflF  :^ 


I.    IXTRACRANIAL. 

(a)  Cerebral: 

1.  Sclerosis. 

2.  Aneurysms. 

3.  Tumors'  involving  some  part  of  the  extent  of  deep  origin 

of  the  nerve. 
(6)  Radical: 

Any  inflammatory  afi^ection  of  the  sheath  of  the  root, 
(c)  Ganglionic: 

Chronic  interstitial  inflammatory  changes  causing  compres- 
sion on  the  nerve  cells. 


II.    CR.VXIAL. 

1.  All  morbid  processes  at  the  base  of  the  skull  and  in  foramina. 

2.  Callus  following  fractures. 

3.  S\'philitic  periostitis. 

4.  Inconstancy  of  shape  and  size  of  foramina. 

III.    EXTR-^CR-VXIAL   OR   PERIPHERAL. 

1.  Dental  caries:  diseases  of  the  dental  pulps,   pericemental,  and 

dento-alveolar  affections. 

2.  Contraction  of  lumina  or  peripheral  bony  canals. 

3.  Exposure  to  cold  or  damp,  producing  perineuritis;  atmospheric 

conditions. 

4.  Retention    of    secretion    in    frontal,    maxillary,    sphenoidal,    or 

ethmoidal  sinuses. 

5.  Diseases  of  the  eye,  ear  and  nose;  nerves  cut  in  cicatrices,  un- 

pacted  foreign  bodies,  malposed  unerupted  teeth,  spiculse  of 
bone,  etc. 

6.  Traumatism. 

1  Jour.  Am.  Med.  Assn.,  October  11,  1902,  p.  897. 
16 


242  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


IV.    TOXIC,    REFLEX    AND    FUNCTIONAL   CAUSES. 

Among  these  are  included  neurotic  temperament,  worry  and  anemia, 
malaria,  digestive  disturbances,  sepsis,  diabetes,  la  grippe,  febrile 
diseases,  rheumatism,  gout,  pregnancy,  hysteria,  alcoholism,  uterine 
or  ovarian  affections,  and  the  influence  of  any  general  disease  that 
may  predispose  by  causing  a  debilitated  condition  of  the  system,  and 
also  lead,  mercury,  arsenic,  nicotin,  and  similar  poisons.  In  the  great 
majority  of  cases  the  disease  process  is  ascending,  beginning  in  the  per- 
ipheral nerve  filaments  and  later  progressing  to  and  involving  the  gan- 
glion. In  a  few  cases,  however,  probably  including  those  benefited  by 
an  extirpation  of  the  ganglion,  the  lesion  has  been  central,  either  in  the 
area  of  distribution  of  the  sensory  root  or  in  the  sensory  root  itself. 

Heredity  plays  no  part  in  the  etiology,  though  in  some  cases  neurotic 
history  is  obtained. 

The  foregoing  may  be  either  predisposing  or  exciting  causes,  or 
both,  but  it  seems  best  not  to  attempt  any  radical  distinction  of  this 
character  in  classification  such  as  is  given  by  some  authors,  because  our 
present  knowledge  of  the  varying  degrees  in  which  causal  influences 
may  be  effective  does  not  warrant  a  distinct  line  of  demarcation. 

Pathology." — The  pathological  alterations  which  might  be  accepted 
as  being  distinctively  representative  of  neuralgia  of  the  fifth  nerve  are 
indefinite.  Certain  changes  in  Gasserian  ganglia  which  have  been 
removed  have  been  demonstrated  by  Gushing,  Spiller,  and  others, 
but  while  it  is  recognized  that  trigeminal  neuralgia  may  be  due  to  cen- 
tral causes  such  as  disease  of  the  pons,  hemorrhage,  softening,  multiple 
sclerosis,  tumor,  or  abscess,  through  which  the  Gasserian  ganglion  or 
the  fifth  nerve  may  become  involved,  it  is  also  caused  by  peripheral 
irritation,  and  in  these  cases  pathological  manifestations  might  be 
confined  to  affected  branches  of  the  nerve,  and  the  Gasserian  ganglion 


DESCRIPTION  OF  PLATE  X. 

Fig.  1. — Portion  of  the  Gasserian  ganglion  at  the  entrance  of  the  third  branch  of  the 
trifacial  nerve.  The  medullary  sheaths  are  most  irregularly  swollen,  and  at  the  right  of 
the  field  empty  nerve  sheaths  are  seen  (method  of  Azoulay). 

Fig.  2. — Portion  of  the  second  branch  of  the  trigeminal  nerve  near  the  Gasserian 
gangUon.  The  axis-cylinders  have  entirely  disappeared,  and  the  medullary  sheaths  are 
greatly  swollen.  In  many  places  the  medullary  substance  of  two  or  more  nerve  fibers 
has  united  into  irregularly  shaped  masses  (osmic  acid  stain). 

Fig.  3. — One  of  the  nerve  bundles  within  the  Gasserian  gangUon.  Numerous  swollen 
and  irregidarly  formed  axis-cylinders  may  be  seen.  In  most  portions  of  the  field  these 
appear  as  drops  of  a  red,  hyaline-like  substance,  but  in  one  portion  an  axis-cylinder  of 
considerable  length  may  be  seen. 

Fig.  4. — Bloodvessels  from  the  Gasserian  ganglion.  The  walls  are  greatly  thickened, 
and  the  lumen  of  the  large  vessel  has  been  almost  entirely  obliterated.  In  one  place  the 
innermost  layers  of  the  vessel  have  contracted  from  the  outer  during  the  process  of  hard- 
ening.   Smaller  vessels  in  the  upper  part  of  the  field  are  entirely  closed. 

Fig.  5,^ — A  nerve  bundle  of  the  trigeminus  close  to  the  Gasserian  ganglion.  Only  a 
few  nerve  fibers  are  present,  and  everywhere  an  abundance  of  connective  tissue  is  seen. 
Three  much  swollen  medullary  sheaths  are  in  the  field.     (After  Starr.) 


PLATE  X 


FIG.   1 


FIG.  4 


FIG.  3 


<S'i 


NEURALGIA  243 

would  probably  not  give  any  indication  of  pathological  structural 
alteration.  Certain  changes,  however,  which  take  j)lace  in  the  pul{)s  of 
other^^■ise  normal  teeth  in  these  cases  (Figs.  115  and  IKi)  lend  color 
to  the  belief  that  there  is  always  structural  alteration  in  the  nerve  or 
its  affected  branches  in  greater  or  less  degree,  and  that  in  the  course  of 
time,  with  progress  of  the  disease,  other  more  remote  portions  of  the 
ne^^■e  undergo  similar  degenerative  changes.  Gordon^  believes  that 
peripheral  nevve  degeneration  is  constantly  present,  and  that  this 
degeneration  assumes  the  form  of  a  neuritis  which  secondarily  involves 
the  Gasserian  ganglion  (Plate  X). 

Changes  in  the  blood^'essels,  indicati\'e  of  arteriosclerosis,  are  fre- 
quent associates  of  this  afl'ection  in  patients  of  advanced  age. 


/ 


Fig     115. — Pulp  showing  calcific  degeneration  removed  from  a  molar  tooth  upon  the 
affected  side  in  a  case  of  tic  douloureux. 

Symptoms. — The  essential  symptom  of  neuralgia  is  pain.  Usually 
the  pain  is  described  as  paroxysmal,  but  in  minor  neuralgia  or  visceral 
referred  pain  in  the  distribution  of  the  trigeminus,  painful  symptoms 
may  appear  in  many  forms.  It  may  be  more  or  less  continuous, 
appear  and  disappear  quickly,  or  show  a  tendency  to  periodic  mani- 
festations, as  at  particular  hours  of  the  day,  certain  days  of  the  month, 
or  under  special  conditions  of  almost  any  kind;  it  may  be  excited  by 
certain  acts,  the  position  of  the  body,  as  in  lying  down  or  standing, 
and  by  moments  of  excitement  or  atmospheric  changes.     Usually 

1  Practical  Medicine  Series,  1906,  x. 


244 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


in  minor  neuralgia,  especially  at  the  beginning,  the  pain  is  confined  to 
the  particuUir  branch  of  the  nerve  that  is  most  affected  by  the  per- 
ipheral irritation,  A\hatever  it  may  be,  and  the  neuralgia  is  described  as 
supra-orbital,  infra-orbital,  temporal,  frontal,  occipital,  etc.  Visceral 
referred  pain  has  a  tendency  to  appear  in  distant  and  otherwise  unaf- 
fected parts.  Other  reflexes  may  also  be  associated  with  the  pain. 
There  may  or  may  not  be  hyperesthesia  or  superficial  tenderness  over 
circumscribed  areas  of  skin  or  mucous  membrane  surfaces  (Fig.  117). 


Fig.  116. — Pulp  showing  calcific  degeneration  removed  from  a  tooth  upon  the  affected 
side  in  a  case  of  tic  douloureux. 


Diagnosis  and  Treatment. — In  the  early  stages  of  neuralgia  it  is  some- 
times difficult  or  impossible  to  distinguish  between  major  and  minor 
forms,  and  it  is  generally  admitted  that  minor  neuralgia  of  peripheral 
origin  may  progress  until  the  central  portions  of  the  nerve  are  attacked. 
The  diagnosis  and  treatment  of  all  forms  of  trigeminal  neuralgia  there- 
fore "\^■ill  be  jointly  considered. 

Tic  Douloureux.  —  Symptoms.  —  In  the  violent   paroxysms  which 
are  indicati\'e  of  this  form  of  neuralgia  there  is  more  or  less  involve- 


NEURALGIA 


245 


ment  of  all  the  functional  elements  of  the  trigeminal  nerve.  The 
symptoms  that  are  expressi^'e  of  all  these  effects  naturally  present 
themselves  in  two  chief  divisions:    (1)    Sensory  Manifestations.  (2) 

Motor,  Vasomotor,  and  Secretory  Ahnormah'ties. 


Endouutrifis 
BlaMUr.' 


ifeuraethenia 
{tpinal  irritation ) 


Broad  liganunts 
nndoiiarut 


* Ovariet: 

Fig.  117. — The  locations  of  referred  pains  and  their  cause.     (Dana,  after  Starr.) 


Cerebrospinal 
Area.  nerves. 

I.     Trigeminus,  facial. 

77.     Vpper  4th  cer\'ical. 
777.     Lower     4th     cer\-ical 

and  1st  dorsal. 

IV.     Upper  6th  dorsal. 

V.    Lower  6th  dorsal. 

VI.     12th  dorsal  and  4th 
lumbar. 


VII.     5th   lumbar   and   5th 
sacral. 


Distribution. 
Face  and  anterior 

scalp. 
Occiput,  neck. 
Upper  extremity. 

Thorax. 

Abdomen,  upper 
lumbar. 

Lumbar     region, 
upper      gluteal, 
anterior,        and 
inner  thigh  and 
knee. 

Lower  gluteal,  pos- 
terior thigh  and 
leg. 


Associated  ganglia 
of  sympathetic.  Distribution. 

4th  cerebral.  Head. 


1st  cerA-ical. 

2d  and  3d  cervical, 

1st  dorsal. 
1st  to  6th  dorsal. 
6th  to  12th  dorsal. 

1st  to  5th  lumbar. 


Head,  ear. 
Heart. 

Lungs. 

Viscera    of    abdomen 

and  testes. 
Pelvic  organs. 


1st  to  5th  sacral.         Pelvic      organs      and 


Sensory  Symptoms. — Pain,  the  all-important  s\Tnptom,  may  be 
accompanied  by  its  antithesis,  anesthesia,  or  any  one  of  a  consider- 
able variety  of  intermediate  sensations;  such  as  burning,  prickling, 
itching,  etc. 

In  the  paroxysmal  form  which  is  typical  of  tic  douloureux  pain 
may  appear  at  the  very  beginning  without  previous  warning  or  appar- 


246  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

ent  cause,  or  it  may  begin  with  symptoms  of  minor  neuralgia  or  visceral 
referred  pain  and  gradually  assume  a  paroxysmal  character.  The 
pain  is  unilateral,  most  frequently  limited  to  the  second  and  third 
divisions  of  the  nerve,  although  it  occasionally  affects  the  first  division 
and  in  advanced  cases  all  the  branches  may  be  involved.  It  seems  to 
occur  more  often  on  the  right  side  than  the  left,  and  to  affect  women 
more  frequently  than  men.  The  distinctive  feature  of  pain  in  tic 
douloureux  is  the  sudden  onset  of  the  paroxysms  and  more  or  less  com- 
plete freedom  from  pain  during  the  intervals  between  them.  The 
intervening  periods  vary  from  a  few  seconds  or  usually  a  few  minutes  to 
hours,  according  to  the  progress  of  the  disease  and  the  condition  of  the 
patient.  Both  the  intensity  and  length  of  duration  of  the  painful 
attacks  are  also  similarly  governed.  In  the  beginning  there  are  often 
quite  considerable  periods  during  which  no  pain  is  felt,  and  at  such 
times  patients  usually  believe  themselves  to  be  improving,  but  almost 
always  there  is  recurrence  of  the  symptoms  and  usually  with  increased 
severity.  This  feature  is  sometimes  deceptive  in  arriving  at  conclusions 
as  to  the  result  of  treatment,  and  much  error  has  undoubtedly  arisen  by 
reason  thereof.  The  paroxysms  may  begin  without  apparent  cause  or 
be  incited  by  very  slight  disturbance,  such  as  draughts  of  cold  air, 
slight  motions  of  any  kind,  particularly  in  speaking,  movement  of  the 
jaws,  swallowing,  laughing,  or  excitement  of  any  kind.  Sometimes 
the  pain  is  confined  to  the  daytime  and  the  patient  rests  well  at  night; 
in  other  cases  it  continues  both  day  and  night.  Occasionally  the  pain 
is  preceded  by  a  peculiar  sensation  variously  expressed,  and  by  some 
authors  termed  an  "  aura."  But  this  is  not  always  present,  and  the  use 
of  the  term  as  in  epilepsy  does  not  seem  to  be  fully  warranted  or  gener- 
ally accepted.  Usually  pain  comes  with  the  quickness  of  an  electric 
current  when  the  wires  are  brought  in  contact.  It  varies  in  severity, 
and  is  described  as  a  feeling  of  being  cut  by  red-hot  knives,  and  of 
pricking,  tearing,  lancinating,  or  boring.  It  is  usually  more  intense  at 
points  of  exit  of  the  nerves,  such  as  the  supra-orbital,  infra-orbital,  or 
mental  foramina.  In  rare  cases  it  extends  to  the  opposite  side,  and 
when  this  occurs  it  is  assumed  to  be  of  central  origin.  The  suffering 
of  these  patients  is  beyond  the  possibility  of  description.  Strangely 
enough,  many  of  them  retain  reasonably  good  health  in  other  respects, 
notwithstanding  the  continued  pain,  loss  of  rest,  and  other  ill  effects. 
In  the  course  of  time,  however,  through  derangement  of  the  nervous 
system,  prevention  of  mastication  of  food  by  the  pain  thus  excited,  and 
loss  of  teeth,  there  is  loss  of  flesh  and  general  breaking  down  which 
renders  such  individuals  pitiful  objects. 

Motor  Symptoms. — The  motor  symptoms  are  evidenced  by  spasmodic 
contraction  of  the  muscles  of  the  jaw,  face  and  head,  or  twitching  of  the 
facial  muscles  and  those  of  the  eyelids,  also  of  the  nose  and  angles  of  the 
mouth  during  the  paroxysms  of  pain.  There  is  often  a  drooping  of  the 
features  upon  the  affected  side  which  gives  evidence  of  slight  paralysis 
of  the  muscles  (Figs.  118,  119  and  120). 


NEURALGIA 


247 


Vasomotor  Symptoms. — Vasomotor  symptoms  may  appear  as  redness 
of  the  affected  side  of  the  face.  SweUing,  which  much  resembles 
angioneurotic  edema,  sometimes  occurs  during  periods  when  par- 
oxysms are  frequent  and  does  not  disappear  between  the  paroxysms, 


Fig.   118. — -Tic   douloureux;   paroxysm  of 
pain. 


Fig.  119. — The  same  man  as  shown  in 
Fig.  118  after  operation. 


but  remains  for  several  days  or  longer  and  cannot  be  accounted  for 
by  any  inflammatory  condition.  Distention  of  the  veins,  unilateral 
perspiration,  changed  appearance  of  the  lips,  and  other  similar  effects 
are  occasionally  noticeable.     The  secretory  aberrations  are  usually 


Fig.   120. — Tic  douloureux;  effect_ol  twenty-five  years  of  suffering. 

marked,  tears  flow  from  the  eyes,  and  the  secretion  of  saliva,  as  well  as 
nasal  mucus,  is  actively  stimulated.  The  general  picture  is  one  of 
distress  and  pain. 

Diagnosis. — The  diagnosis  of  tic  douloureux  is  usually  clear,  inasmuch 
as  it  differs  from  headache  and  other  forms  of  neuralgia  by  its  parox- 


248  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

ysms  and  the  intervals  of  freedom  from  pain  and  from  other  spasmodic 
affections  by  pain.  The  determination  of  whether  the  seat  of  the  neu- 
ralgia is  central  or  peripheral  is  most  important.  To  determine  this 
any  associated  sjTiiptoms  or  pathological  indications  which  might  lead 
to  the  recognition  of  brain  affection  or  some  general  disease  that  might 
be  accountable  for  central  irritation  should  be  carefully  considered. 
Thorough  search  must  be  made  to  ascertain  any  peripheral  cause  that 
might  exist.  This  includes  careful  examination  of  the  eyes,  ears,  nose, 
and  so  far  as  possible  the  maxillary  and  other  associated  sinuses,  as  well 
as  search  for  scars,  results  of  traumatic  injury,  foreign  bodies,  and 
diseased  conditions  of  the  teeth.  (The  diagnosis  of  dental  and  oral 
forms  of  irritation  are  described  on  page  275.) 

Since  the  cause  may  be  looked  for  higher  up  in  proportion  to  the 
number  of  divisions  and  subdivisions  of  the  nerve  that  are  affected, 
it  necessarily  follows  that  each  of  the  several  branches  should  be 
examined  for  evidence  of  pathological  alteration. 

In  a  general  but  somewhat  practical  way  this  may  be  tested  by 
pressure  at  the  points  where  the  nerve  passes  through  the  foramina 
upon  or  near  bone  surfaces.  For  example :  If  pressure  be  made  with 
a  finger  passed  within  the  mouth  along  the  inner  surfaces  of  the  ramus 
of  the  lower  jaw  over  the  point  of  entrance  into  the  inferior  dental 
foramina,  or  over  the  mental,  the  infra-orbital,  or  supra-orbital  fora- 
mina, pain  is  excited  if  the  disese  is  confined  to  one  of  the  branches, 
and  it  will  usually  react  along  the  line  of  the  particular  branch  that  may 
thus  be  irritated.  If,  however,  pain  excited  at  any  of  these  or  similar 
points  is  felt  in  other  branches  or  throughout  the  entire  distiibution 
of  the  nerve,  it  is  an  indication  that  the  degenerative  process  has  pro- 
gressed until  all  of  these  divisions  have  become  involved,  and  in  all 
probability  this  has  occurred  through  involvement  of  the  ganglion. 

Treatment  of  Various  Forms  of  Neuralgia.— The  treatment  of 
trigeminal  neuralgia  resolves  itself  into  non-surgical  and  surgical 
methods.  If  constitutional  diseases  are  found  to  be  the  underlying 
cause,  these  must  receive  proper  attention.  Every  possible  source  of 
peripheral  irritation  must  be  removed,  or  the  likeliliood  of  its  acting 
as  an  excitant  guarded  against.  The  eyes  must  be  examined  not  only 
for  visual  defects,  but  for  choked  disk,  partial  or  complete  blindness, 
or  other  indication  of  brain  affection,  or  any  disease  of  the  eye  or  its 
associated  parts  which  might  directly  or  indirectly  be  etiological  factors. 
The  nose  and  its  secretions,  membrane,  septal,  turbinal,  or  other 
deformities,  should  be  examined  and  corrected  if  necessary.  In  like 
manner  the  ear  and  the  frontal,  ethmoidal,  sphenoidal,  and  maxillary 
sinuses  should  be  duly  examined,  and  treatment  applied  if  indicated. 
The  mouth  and  teeth  should  be  tested  and  treated  as  described  on  page 
289.  Habits  of  life  must  be  duly  considered  and  their  correction 
directed.  Ovarian,  uterine,  or  other  organic  disease  should  be  sought 
for  and  treated  if  necessary;  the  intestinal  tract  cleansed  and  duly 
regulated;  digestive  conditions  safeguarded;  and  occupation,  if  disad- 


NEURALGIA  249 

vantageoiis,  readjusted  to  give  necessary  relief.  The  general  nervous 
condition  must  be  i)atiently  studied  and  insofar  as  possible  controlled 
according  to  the  best  psychotherapeutic  methods.  The  observance  of 
thoroughly  good  hygienic  rules  must  be  insisted  upon,  including  diet, 
abundance  of  fresh  air,  exercise,  and  massage. 

Massage. — Care  should  be  taken  in  giving  massage  to  these  patients 
to  see  that  it  is  properly'  done.  The  usual  rubbing  given  by  imrses 
in  hospitals  cannot  be  depended  upon,  and  occasionally  does  more 
harm  than  good  in  exciting  the  circulation  disadvantageously.  Such 
manipulations  should  be  carried  toward  the  extremities  away  from 
the  head,  and  central  regions,  and  be  chiefly  in  the  nature  of  a  gentle 
stroking  with  sufficient  muscular  kneading  to  give  continued  effect 
and  general  stimulation,  as  well  as  rubbing  along  the  spinal  column. 
The  personal  effect  of  the  one  administering  the  massage  in  relation 
to  the  subject  is  important.  The  rubbing  of  one  nurse  or  attendant 
may  cause  increased  nervousness  and  wakefulness,  with  augmentation 
of  the  pain,  while  uilder  the  manipulation  of  another  in  almost  precisely 
the  same  manner  the  same  patient  may  feel  rested,  become  relaxed  and 
drowsy,  with  marked  diminution,  if  not  complete  cessation,  of  the 
pain. 

Medicinal  Treatment. — Examination  of  twenty-four  hours'  urine  for 
these  patients  quite  frequently  shows  more  or  less  marked  variation 
from  normal  quantity,  and  almost  invariably  a  high  degree  of  acidity 
with  marked  increase  of  indican.  The  latter  is  a  product  of  indol, 
which  is  a  result  of  intestinal  fermentation,  and  this  state  is  usually 
further  evidenced  by  tendency  to  constipation  and  other  disturbances 
of  the  digestive  tract.  It  therefore  follows  that  this  region  should 
receive  attention.  Drinking  water  freely  or  the  use  of  diuretics  may 
be  demanded.  Purgation  with  calomel  sometimes  gives  a  measure  of 
relief  in  certain  forms  of  attacks. 

Castor  Oil. — The  continued  use  of  small  doses  of  castor  oil  has  been 
highly  recommended  as  being  more  permanently  beneficial.  Its  use 
is  based  upon  the  theory  that  such  neuralgia  is  of  toxic  origin  and  that 
a  prolonged  evacuant  treatment  should  benefit — two  or  three  good- 
sized  doses  of  castor  oil  every  day  for  a  period  of  two  or  three  weeks. 
When  the  laxative  effect  has  been  thoroughly  produced  it  ceases  to  give 
distress  and  serves  a  very  effective  purpose.  This  treatment  was 
advocated  by  Strohmeyer  in  1864. 

Gelsemium. — Fifteen  drops  of  the  green  tincture  given  every  few 
hours  for  a  few  days,  or  until  the  physiological  limit  is  reached,  which 
will  be  noted  by  the  patient  beginning  to  see  everything  in  yellow 
colors,  is  one  of  the  highly  recommended  remedies. 

Miscellaneokis  Drugs  and  Measures. — Hot  foot  baths  and  hot  appli- 
cations to  the  feet  tend  to  draw  blood  from  the  head  and  to  cause  a 
general  relaxation  which  is  often  very  helpful.  Applications  of  heat  or 
cold  or  liniments  over  the  affected  region  have  a  grateful  effect.  Many 
of  these  patients  are  anemic,  and  for  these  ovoferrin  for  improvement 


250  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

of  the  hemoglobin  or  other  tonics,  and  such  general  restoratives  as 
quinin,  cod-liver  oil,  or  the  phosphates  are  beneficial.  Arsenic,  potas- 
sium iodide,  and  mercury  have  their  proper  places  in  the  list  of  reme- 
dies, especially  when  syphilis  is  suspected  as  a  causative  influence. 
Electricity,  chiefly  employed  in  the  form  of  electrolysis  and  a  high- 
frequency  current,  has  a  measure  of  value,  and  has  been  highly  recom- 
mended. Its  possibilities,  like  those  of  the  a--rays  and  radium,  also 
well  recommended,  have  yet  to  be  definitely  determined.  Hypnotic 
drugs  should  only  be  given  as  a  last  resort,  and  then  only  with  the 
greatest  care  of  administration,  because  the  tendency  of  all  these 
patients  is  ultimately  to  seek  relief  of  this  character,  and  the  danger 
of  the  drug  habit  is  always  a  menace.  Bromides,  chloral,  opium  in 
its  various  forms,  especially  codeine  and  morphin,  and  other  similar 
remedies  are  all  capable  of  giving  temporary  relief,  but  when  once 
dependence  has  been  placed  upon  them  the  demand  becomes  more 
constant  and  the  required  doses  larger  until,  with  almost  unfailing 
certainty,  disaster  follows. 

Antipyrin,  phenacetin,  and  salicylates  have  an  undoubted  place, 
especially  with  rheumatic  persons.  In  a  general  way,  however,  it  may 
be  safely  stated  that  when  no  relief  can  be  given  by  measures  which 
without  harm  in  other  respects  tend  to  restore  normal  physiological 
function  in  deranged  parts,  upbuild  general  health  and  resistance  or 
correct  nervous  states,  or  when  no  actual  peripheral  cause  can  be 
discovered  through  correction  of  which  relief  may  be  given,  then, 
instead  of  relying  upon  drugs,  the  only  rational  treatment  must  be 
in  the  nature  of  injections  into  the  nerve  at  accessible  points  in  the 
course  of  the  affected  branches,  or  operations  upon  the  nerve  or  the 
Gasserian  ganglion. 

The  Injection  of  Osmic  Acid  Directly  into  the  Nerve. — A  1.5  per  cent, 
solution  has  been  advocated  by  Bennet,  Murphy,  Hammerschleig, 
and  others  with  reports  of  cases  benefited.  Its  effectiveness  depends 
upon  two  factors — the  destruction  of  nerve  filaments  and  their  substi- 
tution by  connective  tissue. 

Favorable  results  from  the  use  of  osmic  acid  in  9  patients  are  reported 
by  R.  Hammerschleig.^  A  1  per  cent,  aqueous  solution  was  injected 
into  the  infra-orbital  and  mental  foramina.  In  8  of  the  patients  the 
pain  has  not  recurred  for  intervals  varying  from  four  months  to  as 
many  years;  in  the  last  case  there  was  great  improvement. 

Murphy  claims  that  the  osmic  acid  gives  a  longer  period  of  relief 
on  the  average  than  any  method  except  removal  of  the  ganglion  or 
the  metallic  plugging  of  the  foramina.  He  reports  a  number  of  his 
cases  as  well  after  the  lapse  of  four  years. 

As  long  as  a  feeling  of  numbness  which  gives  a  measure  of  discomfort 
is  felt  in  the  region  supplied  by  the  injected  branch  of  the  nerve  in  cases 
where  the  trouble  is  confined  to  the  division  so  treated,  there  is  relief 

'  Arch.  f.  klin.  Chir.,  1906,  Ixxix,  1050;  Practical  Medicine  Series,  1907,  x,  181. 


NEURALGIA  251 

from  pain.     When,  however,  the  patients  report  that  the  face  feels 
quite  natural  again,  it  usually  follows  that  i)ain  quickly  returns. 

Injections  of  Alcohol. — Alcohol  by  deep  injection  into  the  nerve 
trunk  was  first  ]3erformed  by  Schlosser,  of  Munich.  The  method 
of  performing  has  been  improved  by  Otswald,  Levi,  Baudouin,  and 
Patrick.  From  70  per  cent,  to  90  per  cent,  alcohol  is  used  with  a 
little  cocain  or  stovain  to  prevent  pain  or  discomfort  from  the  injection. 
Patrick's^  alcohol  solution  is  as  follows : 

'Bf — Cocain  hydroclilorate gr.  j 

Chloroform TTlx 

Alcohol 5iv 

DistOlcd  water,  sufficient  to  make gss — M. 

Of  this  he  injects  2  c.c.  For  succeeding  injections  the  proportion 
for  alcohol  is  increased  gradually  up  to  90  per  cent.,  the  amount  of 
cocain  being  also  increased. 

The  instrument  is  a  needle  of  large  caliber,  about  12  cm.  long,  marked 
off  in  centimeters  up  to  5,  beginning  at  the  point.  This  is  fitted  with  a 
stylet  of  such  length  that  when  pushed  home  the  end  is  flush  with  the 
point  of  the  needle.  For  the  injection  a  syringe  holding  2  c.c.  is  em- 
ployed, the  nozzle  of  which  will  fit  snugly  into  the  end  of  the  needle. 

For  the  inferior  maxillary  branch  of  the  fifth  nerve  the  needle  is 
inserted  at  the  lower  border  of  the  zygoma,  2.5  cm.  in  front  of  the 
anterior  border  of  the  external  auditory  meatus.  The  bony  ridge  of 
the  temporal  bone,  as  well  as  the  descending  root  of  the  zygoma,  can 
always  be  felt  along  the  front  border  of  the  meatus.  The  stylet  is 
partly  withdrawn,  the  point  of  the  needle  pushed  through  the  skin 
and  subcutaneous  tissue,  and  the  stylet  is  then  pushed  home,  so  that 
for  the  remainder  of  the  penetration  the  blunt  end  of  the  stylet 
serves  instead  of  the  sharp  point  of  the  needle.  This  is  to  prevent 
the  possible  transfixion  of  bloodvessels.  The  needle  is  then  pushed 
inward  in  a  plane  at  right  angles  to  the  side  of  the  face  and  inclined  a 
little  backward  to  the  depth  of  4  cm.  At  that  depth  the  point  should 
reach  the  inferior  branch  of  the  fifth  nerve  as  it  emerges  from  the 
foramen  ovale.  The  stylet  is  then  withdrawn,  the  syringe  fitted  to 
the  needle,  and  the  injection  slowly  made. 

For  the  superior  maxillary  division  of  the  fifth,  the  point  of  entrance 
is  at  the  lower  border  of  the  zygoma,  0.5  cm.  posterior  to  the  point 
which  would  be  reached  by  prolonging  downward  the  line  of  the 
posterior  border  of  the  perpendicular  process  of  the  malar  bone.  From 
this  point  the  needle  is  passed  almost  perpendicularly  inward,  being 
inclined  forward  and  upward.  At  a  depth  of  5  cm.  the  point  should 
reach  the  nerve  at  its  emergence  from  the  foramen  rotundum  into  the 
sphenomaxillary  fossa. ^ 

The  author  modifies  Patrick's  procedure  by  injecting  novocain 
with  a  small  syringe  at  exactly  the  point  and  in  the  direction  to  be 
followed  by  the  large  caliber  needle  and  stylet.    This   is   done  by 

1  Practical  Medicine  Series,  1907,  x,  172.  ^  ibid.,  x,  169. 


252 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


injecting  a  little  novocain  just  under  the  skin,  and  from  time  to  time, 
as  the  point  of  the  needle  penetrates.  By  carrying  the  needle  in, 
almost  but  not  quite,  to  the  point  to  be  reached  by  the  alcohol  injec- 


FiG.  121. — lUustration  of  the  point  of  entrance  and  direction  of  the  cannula  and 
stylet  for  injection  of  the  superior  maxillarj'  di^^sion  of  the  fifth  nerve  at  the  foramen 
rotundum — is  calculated  from  a  point  1  cm.  posterior  to  the  external  angular  process 
in  a  direct  line  downward  to  a  point  just  below  the  zj^goma.  The  point  is  inclined  forward 
and  upward,  and  forced  in  to  a  depth  of  5  cm.  Care  must  be  taken  to  have  the  patient 
look  upward  to  avoid  possible  injurj^  to  the  eye  muscles.  The  author  prefers  to  have  the 
patient  lie  on  the  opposite  side  with  the  head  supported  on  a  pillow,  to  facilitate  accuracy 
in  the  direction  of  the  sj-ringe  point. 

tion,  the  insertion  of  the  large  syringe  is  rendered  much  less  painful. 
Care  must  be  taken,  however,  not  to  penetrate  deeply  enough  to 
anesthetize  the  branch  of  the  nerve  to  be  injected.     Even  though  the 


Fig.  122. — Injection  of  the  inferior  maxillary  division  of  the  fifth  nerve  at  the  foramen 
ovale  2.5  cm.  in  front  of  the  external  auditor^'  meatus.  The  point  is  forced  straight  in 
to  a  depth  of  4  cm. 


point  of  entrance,  the  direction,  and  the  depth  of  the  injection  may 
be  ever  so  carefully  calculated,  slight  anatomical  differences  in 
individuals  renders  it  necessary  that  the  sharp  pain  must  be  felt  when 


NEURALGIA 


253 


the  syrmo;e  point  reaches  the  foramen  ovale  or  the  foramen  rotimdum. 
The  radiation  of  pain  throughout  the  area  of  distribution  of  the 
injected  nerve  gives  certain  indication  that  the  objective  point  has 
been  reached.     (See  Figs.  121  and  122.) 

Diseases  of  the  sphenopalatine  or  nasal  ganglion  have  been  described 
by  Dunn'  and  Sluder.^  Sluder  says  that  such  attacks  of  pain  resemble 
those  of  maxillary  and  vidian  neuralgia  excited  from  within  the  sphe- 
noidal sinus.  If  due  to  an  affection  of  Meckel's  ganglion  cocainization 
of  this  structure  gives  relief,  which  is  not  the  case  when  it  originates 
from  the  sphenoidal  district.  Applications  of  2  per  cent,  silver  nitrate 
or  1  per  cent,  formaldehyde  to  the  membrane  of  the  sphenopalatine 
foramen  often  cure  the  mild  and  subacute  cases,  while  in  severe  ones 
injections  of  alcohol  are  required. 


Fig.  123. — To  show  measurements  to  be  taken  for  locating  foramen  ovale  and  foramen 
rotundum.     Explanation  in  text.      (Offerhaus.) 


Offerhaus^  gives  the  following  measurements  of  sixty  skulls  to  perfect 
the  landmarks  for  the  location  of  the  foramen  rotundum  and  the 
foramen  ovale,  upon  which  he  bases  the  rules  for  his  improved  method 
of  locating  foramina  for  deep  indications  of  the  trifacial  nerve: 

"(1)  The  distance  between  the  foramina  ovale  (  D.  F.  0.  on  Fig.  123) 
equals  that  between  the  alveolar  processes  of  the  upper  jaw,  measured 

1  Glasgow  Med.  .Jour.,  August,  1915,  p.  98.  ^  Lancet-Clinic,  April  24,  1915. 

3  Practical  Medicine  Series,  1910,  x,  149;  after  Arch.  f.  klin.  Chir.,  1910,  xcii,  47. 


254  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

in  the  mouth  between  theh  outer  borders  behind  the  last  molars  at  the 
tuberosities  (pyramidal  processes)  of  the  palate  bone  (D.  A.  E.,  Fig. 
123).  (2)  On  making  frontal  sections  through  the  skull  just  in  front 
of  the  tuberosities  (tuber  maxillare),  the  foramina  ovale  are  seen  either 
in  the  section  or,  more  frequently,  1  to  6  mm.  posteriorly,  and  3  or 
4  mm.  above  a  line  (linea  intertubercularis,  L.  T.,  Fig.  123)  uniting  the 
inferior  borders  of  these  tuberosities.  (3)  The  distance  between  the 
foramina  rotunda  equals  the  distance  between  the  alveolar  processes 
of  the  upper  jaw,  measured  internally,  behind  or  at  the  last  molar 
{D.  A.  1.,  Fig.  123).  (4)  The  foramina  rotunda  lead  to  the  upper  and 
posterior  part  of  the  sphenopalatine  fossa,  while  the  sphenopalatine 
foramina  are  on  the  mesial  side.  A  line  (linea  interzygomatica,  L.  Z., 
Fig.  123)  uniting  the  latter  crosses  the  upper  border  of  the  zygoma  at 
its  middle  or  at  the  junction  of  its  temporal  and  malar  portions.  The 
foramina  rotunda  lie  2  to  4  mm.  above  and  slightly  behind  this  line. 
(5)  The  distances  from  the  foramen  ovile  to  the  outer  border  of  the 
tuberosity  (tuberculum  articulare)  (D.  0.  T.,  Fig.  123),  and  from  the 
foramen  rotundum  to  the  outer  border  of  the  zygoma,  are  equal  on 
the  right  and  left  sides  except  in  the  few  very  as^^nmetrical  skulls. 

"In  vivo,  in  order  to  determine  the  depth  of  the  foramen  ovale 
it  suffices  to  measure  the  distantia  interalveolaris  externa  (D.  A.  E.) 
and  the  distantia  intertubercularis  {L.  T.).  If  the  former,  for  example, 
is  5  cm.  and  the  latter  14  cm.,  then  the  foramen  ovale  is  at  a  depth  of 

—^  =  4.5  cm.  The  same  is  true  of  the  second  branch  of  the  tri- 
geminus and  the  foramen  rotundimi,  mutatis  mutandis.  In  the  living, 
howe^•er,  it  is  not  easy  to  determine  the  exact  direction  of  the  linea 
intertubercularis  and  interzygomatica,  so  I  have  constructed  a  caliper 
with  movable  rods  at  the  ends  (Fig.  124).  The  caliper  is  placed  on 
the  tubercula  articularia,  which  are  readily  felt  through  the  skin,  and 
the  distance  measured;  then  the  caliper  is  removed,  placed  at  the  same 
width,  the  rods  are  placed  in  line,  and  the  instrument  put  back  on  the 
tubercula,  when  the  rods  indicate  the  proper  direction  in  which  to 
introduce  the  needle  (Fig.  125)." 

The  author  also  gives  rules  for  directing  a  curved  needle  from  the 
mouth  through  the  foramen  ovale  in  such  a  way  that  the  Gasserian 
ganglion  itself  may  be  injected  (Fig.  126). 

The  Fliirtel  method  of  injecting  the  Gasserian  ganglion  is  the  one  now 
more  generally  adopted.  The  left  index  finger  is  placed  between  the 
jaw  and  cheek  with  the  patient's  mouth  closed.  The  space  between 
the  coronoid  process  of  the  mandible  and  the  maxillary  tubercle  is 
located.  The  cannula  is  introduced  into  the  cheek  at  a  point  opposite 
the  second  molar.  With  the  finger  inside  the  mouth  as  a  guide,  the  can- 
nula is  forced  subcutaneously  between  the  mandible  and  the  maxillary 
tubercle,  directly  upward  until  the  hard  smooth  surface  of  the  sphenoid 
bone  is  felt.     Hartel  calls  particular  attention  to  the  necessity  for 


NEURALGIA 


255 


proper  alignment  of  the  cannula  at  this  point  in  the  procedure,  so  that 
a  line  drawn  vertically  upward  from  the  point  of  entrance  of  the  needle 
into  the  skin  will  bisect  the  pupil  of  the  eye  when  looked  at  from  the 
front,  but  if  looked  at  from  the  side  it  will  bisect  the  articular  eminence 
of  the  zygoma  (see  Fig.  127).  The  cannula  is  now  pushed  backward 
and  slightly  upward  until  the  guard  on  the  cannula  which  has  been 
fixed  at  6  cm.  indicates  that  this  depth  has  been  reached.  Slight  move- 
ment of  the  point  of  the  cannula  over  the  smooth  surface  of  the  bone 
gives  indication,  when  the  resistance  is  no  longer  felt,  that  the  point 
has  penetrated  into  the  skull  through  the  foramen  ovale. 


Fig.   124. — -Instrumeiit  used  for  determining  direction  of  needle.     (Offerhaus.; 


Approximately  2  c.c.  of  80  per  cent,  alcohol  is  injected  into  the 
ganglion,  a  few  drops  at  a  time.  Dorrance  advocates  moving  the  point 
of  the  syringe  from  side  to  side  in  order  to  come  in  contact  with  as 
much  of  the  ganglion  as  possible. 

The  after-treatment  consists  in  covering  the  point  of  the  puncture  of 
the  skin  surface  with  collodion  dressing.  The  eyes  need  protection 
and  care  following  the  alcohol  injection  of  the  Gasserian  ganglion,  the 
same  as  after  the  ganglion  operation.  They  should  be  flushed  with 
boric  acid  solution  and  protected  with  watch-glass  crystals,  suitably 
arranged  with  cotton  or  felt  rings.     Close  observation  and  care  of  the 


256  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


Fig.   125. — Instrument  i7i  situ  preparatory  to  injection  of  inferior  maxillary  nerve   at 
foramen  ovale.      (Offerhaus.) 


Fig.   126. — Method  of  reaching  Gasserian  ganglion  through  foramen  ovale.      (Offerhaus.) 


NEURALGIA 


257 


eyes  should  be  ^'iven  for  eight  to  ten  days  after  the  injection.   The  chief 
danger  appears  to  be  loss  of  vision  of  the  eye  on  the  affected  side. 

But  there  is  also  danger  of  a  puncture  of  the  internal  maxillary 
artery,  of  injection  into  the  Eustachian  tube,  of  coming  in  contact 
with  a  rough  bone  surface  and  therefore  being  below  the  foramen. 
Complications  of  the  oculomotor  nerve,  facial  nerve,  and  the  soft 
palate,  herpes  facialis,  keratitis,  corneal  ulcer,  and  paralysis  of  the 
sixth  nerve  have  been  reported  by  Hartel  and  others. 


Fig.  127. — Illustration  of  the  point  of  entrance  tlirough  the  cheek  and  the  direction 
of  the  cann\ila  for  alcoholic  injection  of  the  Gasserian  gangUon.  Hartel's  hne  to  bisect 
the  pupil  of  the  eye  when  looked  at  from  the  front  is  marked  as  recommended  by  Dorrance, 

A  few  deaths  from  ulcer  ha^'e  been  reported  and  in  most  of  these 
cases  there  appears  to  have  been  some  other  complication.  There 
seems  to  be  freedom  from  these  objections  with  improved  technic,  and 
it  is  not  unlikely  that  this  may,  in  the  course  of  time,  entirely  supplant 
more  serious  operative  features  for  the  relief  of  tic  douloureux.^ 

The  reports  of  the  result  of  this  treatment  var}'  considerably,  and 
but  few  authors  claim  that  trigeminal  neuralgia  can  be  permanently 
cured  in  this  way.  All,  however,  are  agreed  that  a  measure  of  relief 
can  be  given,  which  may  last  from  a  few  days  to  months  or  even  a  year 
or  more.  Schl5sser  reports  123  cases  with  cessation  of  pain  during  the 
average  period  of  ten  and  two-tenths  months.  Brissoud,^  Cicard,  and 
Tanon  report  18  cases,  with  an  average  relief  from  tlu-ee  to  five  months. 
Patrick  urges  in  its  favor  that  the  operation  is  practically  devoid  of 


1  Dorrance,  Geo.,  PhUa. :  "Injection  Gasserian  Ganglion,"  Dental  Cosmos,  January, 
1916;  Byrnes,  C.  M.,  "Alcohol  Injection  Gasserian  Ganglion,"  Johns  Hopkins  Hospital 
Bulletin,  January,  1915. 

2  Revue  Neurolog.,  March  30,  1907. 

17 


258  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

danger,  requires  no  anesthetic,  that  rehef  can  be  given  in  many  cases 
for  a  year  or  more,  with  but  httle  inconvenience  to  the  patient. 

The  author's  experience,  based  upon  the  observation  of  many 
patients  who  have  come  under  his  care  after  having  previously  had 
alcohol  and  osmic  acid  injections,  according  to  the  old  methods  of 
peripheral  treatment  are  not  favorable.  In  almost  all  of  these  cases 
the  period  of  relief  was  hardly  sufficient  to  compensate  for  the  dis- 
comfort following  the  injection,  and  in  some  of  them  even  repeated 
injections  had  failed  to  give  the  desired  relief.  More  modern  technic 
in  the  deep  alcoholic  injections  of  the  superior  maxillary  division  at  the 
foramen  rotundum,  and  the  inferior  maxillary  division  at  the  foramen 
ovale,  have  been  so  satisfactory  in  their  results  as  to  make  many  of  the 
peripheral  operations,  which  the  author  performed  frequently  in  the 
past,  quite  unnecessary. 

There  is  a  considerable  difference  in  individual  cases  in  the  results 
of  these  injections.  Occasionally  the  severe  immediate  pain  is  quickly 
followed  by  numbness  along  the  line  of  the  distribution  of  the  nerve, 
and  relief  from  pain.  Sometimes  this  disappears  quickly,  sensation, 
and  ultimately  pain  returning.  In  other  cases  there  seems  to  be  a  hard 
battle  between  the  nerve  tissues  and  the  alcohol,  and  more  or  less  pain 
continues  for  some  time,  after  which  there  may  be  a  long  period  of 
relief.  Occasionally  it  is  necessary  to  make  a  reinjection  in  a  short 
time,  and  even  then  the  desired  relief  may  come  very  slowly.  But  the 
difficulties  of  injection  are  so  slight  when  compared  with  any  kind  of 
operation,  and  the  suffering  of  these  patients  is  so  great,  that  this 
feature  of  the  treatment  is  comparatively  inconsiderable  when  the  more 
or  less  continuous  torture  is  considered.  The  necessity  for  repeating 
the  injection  is  after  all  not  a  serious  matter.  The  continued  injection 
of  alcohol  in  the  close  vicinity,  or  in  actual  contact  with  the  nerve  must 
almost  surely  cause  degenerative  changes  which  will  give  ultimate 
relief  of  sufficiently  enduring  character. 

SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA. 

Neurotomy. — Simple  division  of  the  nerve  was  suggested  by  Albinus 
and  Galen  and  first  performed  by  Schlichting  in  1748,  It  is  of  little 
value  because  of  rapid  regeneration. 

Neurectomy. — Excision  of  a  section  of  a  nerve  was  first  performed  in 
1793  by  Abernethy.  The  piece  removed  should  not  be  shorter  than 
1  cm.,  but  even  with  this  method  regeneration  is  not  entirely  pre- 
vented. 

Nerve  Extraction. — ^According  to  the  method  of  Thiersch  extensive 
extirpation  of  nerves  is  done  by  grasping  the  ends  of  the  nerve  with  a 
forceps  which  is  slowly  turned  a  half-turn  every  second  or  slower,  until 
as  much  as  possible  of  the  nerve  has  been  removed  (Fig.  128). 

Nerve  Stretching. — This  operation  was  first  performed  on  the  tri- 
geminus by  Vogt  in  1876  but  it  is  not  permanently  effective. 


SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA       259 

Other  Methods. — Thiersch  recommended  the  removal  of  paivjnl  scars 
with  neurotomy  or  in  combination  with  other  operations.  Crushing 
and  cauterizing  the  central  end  of  the  divided  nerve  was  done  by  Klein 


Fig.  128. — Inframaxillary  nerve  extracted,  according  to  Thiersch,  from  a  man  aged 
forty-three  years.  Ch.  L,  chorda  tympani;  L,  lingual  nerve;  a.  i.,  inferior  dental  nerve. 
Five-sixths  natural  size.     (After  Bull-Von  Bergmann.) 

in  1822,  and  the  peripheral  end  by  Boyer.  Galvanocautery  has  been 
used  to  divide  the  nerve.  Splitting  one  or  both  ends  and  turning  them 
hack  into  a  loop  was  suggested  by  Malgaigne.  Plugging  of  the  foramina 
to  prevent  regeneration  of  the  nerve  has  also  been  employed. 


260 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


Operations  for  Exposure  of  the  First  Trigeminal  Branch  (Ophthalmic 
Nerve). — The  eyebrows  are  shaved,  the  skin  surface  is  properly  pre- 
pared, and  an  incision  following  the  outline  of  the  e\'ebro\v  is  made 
of  sufficient  length  to  give  freedom  in  exposure  of  the  nerve.  The  tis- 
sues are  divided  down  to  the  supra-orbital  notch  through  which  the 
nerve  passes.  The  nerve  is  grasped  with  a  forceps,  separated  from  the 
surrounding  orbital  fat,  which  may  be  facilitated  by  care  to  avoid 
laceration  in  separating  the  periosteum.  The  nerve  is  then  drawn  out 
until  the  supratrochlear  nerve  is  brought  into  view.  The  nerve  is 
divided  behind  this  branch  and  a  sufficient  amount  of  the  peripheral 
portion  of  the  nerve  is  removed.  It  is  possible  to  reach  the  lacrimal 
nerve  where  it  leaves  the  ophthalmic  far  back  in  the  cavity  of  the  orbit, 
and  the  ethmoid  nerve  at  its  point  of  entrance  into  the  anterior  eth- 


FiG.    129. — Exposure  of  the  supra-orbital  and  supratrochlear  nerve  at  the  right  eye. 
Incision  to  expose  the  infra-orbital  ner^-e  at  the  left  eye.     Two-thirds  natural  size. 

moidal  foramen  at  the  inner  and  upper  aspect  of  the  orbit.  The  com- 
parative unimportance  of  these  branches,  however,  when  weighed 
against  the  possibility  of  serious  affections  of  the  eye  following  disturb- 
ance of  the  contents  of  the  orbit  makes  it  doubtful  whether  search 
for  these  smaller,  more  deeply  seated  branches  is  warranted  except 
under  rare  conditions.  Krause  states  that  he  has  seen  very  severe 
iritis  develop  after  extraction  of  the  supra-orbital  nerve  which  left 
behind  a  spot  on  the  cornea  (Fig.  129). 

Operation  upon  the  Second  or  Infra-orbital  Division  of  the  Fifth  (Figs. 
130  and  131). — The  approach  of  the  infra-orbital  foramen  through 
which  this  nerve  passes  may  be  accomplished  in  two  ways.  The  one 
is  through  an  external  incision  begun  about  0.5  cm.  beneath  the  mesial 
end  of  the  infra-orbital  margin  and  extended  obliquely  downward  and 
outward  to  the  lower  border  of  the  malar  bone.    Sometimes  a  circular 


SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA       261 


Fig.  130. — Various  iacisions  for  reaching  different  branches  of  the  trifacial  nerve: 
a,  supra-orbital;  b,  external  nasal;  c,  Bruns'  incision;  d,  inf.  dent,  at  mental  foramen; 
e,  internal  nasal;/,  infra-orbital;  g,  Carnochan's  incision.      (Marion.) 


Fig.  131. — Exposure  of  the  supra-orbital  and  infra-orbital  branches  of  the  fifth  nerve. 


262 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


incision  following  the  outline  of  the  orbit  is  used,  and  for  more  extensive 
dissections  a  T-shaped  incision  is  used,  the  perpendicular  portion 
extending  from  the  infra-orbital  to  a  point  near  the  angle  of  the  mouth. 
On  account  of  the  unsightly  scar  the  larger  incisions  are  to  be  avoided  if 
possible.  When  the  nerve  is  exposed  at  the  infra-orbital  foramen 
it  may  be  raised  with  a  hook  or  grasped  in  a  forceps,  a  portion  is 
resected,  and  the  infra-orbital  canal  is  plugged  with  a  screw,  as  recom- 
mended by  Mayo,  or  else  by  a  metal  plug  such  as  the  silver  buttons 
used  by  Moschcowitz^  and  illustrated  in  Fig.  132,  or  a  plug  of  metal, 
wax  or  other  non-irritating  substance.  Otherwise  the  more  extensive 
operations  as  described  by  Krause^  ma}^  be  performed. 

"The  length  of  the  incision  is  4  cm.  At  first 
the  incision  is  carried  only  through  skin  and  fasciae 
down  to  the  levator  labii  superioris  (musculus 
quadratus  labii  superioris),  care  being  taken  to 
avoid  the  branches  of  the  facial  nerve.  The  fibers 
of  the  muscle  run  downward  and  across  the  in- 
cision. The  upper  branches  of  the  infra-orbital 
nerve  (palpebral  and  nasal)  appear  in  the  incision, 
since  they  run  upward  to  the  upper  edge  of  the 
wound.  They  are  to  be  spared.  Search  is  then 
made  for  the  infra-orbital  foramen;  it  lies  in  the 
uppermost  part  of  the  canine  fossa,  as  a  rule  1 
cm.  beneath  the  bony  infra-orbital  margin  and 
generally  somewhat  on  the  inner  side  of  its  center. 
Over  it  the  origin  of  the  levator  labii  superioris 
and  the  periosteum  are  divided  down  to  the  bone 
transversely,  and  the  periosteum  then  reflected 
downward  with  a  raspatory  until  the  infra-orbital 
plexus  is  completely  exposed.  The  latter  is  dis- 
sected free  from  the  infra-orbital  artery,  freed 
bluntly  for  a  distance  from  the  surrounding  fatty 
tissue,  and  grasped  with  a  clamp.  Now  the  periosteum  of  the  orbital 
margin  and  of  the  floor  of  the  orbit  is  reflected  as  far  as  possible 
into  the  latter.  If  the  entire  contents  of  the  orbit  are  carefully  raised 
with  a  broad  hook  the  nerve  can  almost  always  be  seen  shining  through 
the  thin  upper  wall  of  the  canal  as  a  white  streak  as  soon  as  the  hemor- 
rhage, which  is  always  slight,  has  ceased.  Farther  backward  it  is 
often  seen  lying  free  in  the  sulcus.  The  canal  runs  a  rather  straight 
course  from  behind  forward;  its  bony  walls  are  thin,  except  in  its  most 
anterior  portion,  where  for  the  distance  of  about  0.5  cm.  the  upper 
wall  is  formed  by  the  broad  infra-orbital  margin.  Here  a  wedge- 
shaped  piece  of  bone  is  removed  with  a  small  chisel;  farther  backward 
the  protecting  layer  of  bone  can  generally  be  broken  off  with  anatomical 

1  Alexis  von  Moschcowitz:  Med.  Record,  September  29,   1906;  Practical  Medicine 
Series,  1907. 

2  Bull  and  von  Bergmann:  System  of  Practical  Surgery,  vol.  i,  p.  574. 


Fig.  132.  —  Silver 
buttons  used  by 
Moschcowitz  to  plug 
the  infra-orbital  fora- 
men in  treatment  of 
trigeminal  neuralgia. 


SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA       263 

forceps.  In  this  way  all  the  structures  filling  the  infra-orbital  canal 
are  laid  bare  up  to  the  sphenomaxillary  fissures,  and  are  then  bluntly 
lifted  out  of  the  bony  furrow.  They  consist  of  the  infra-orbital  nerve, 
artery,  and  veins;  the  artery  accompanying  the  nerve  lies  on  its  inner 
and  under  side." 

The  author  believes  that  external  openings  for  operation  upon 
this  branch  of  the  nerve  are  unnecessary  and  to  be  avoided  because 
of  the  unsightly  scars.  The  class  of  cases  in  which  peripheral  operation 
upon  this  division  of  the  nerve  is  successful  is  usually  quite  as  much 
benefited  without  the  danger  and  difficulty  of  following  the  nerve  into 
the  deeper  portions  of  the  bone,  because  cases  of  central  origin  or  those 
in  which  the  disease  has  progressed  beyond  the  limits  of  more  external 
peripheral  limitations  are  usually  such  as  require  operations  upon  the 
ganglion,  or  at  least  extracranial  operations  at  the  base  of  the  skull 
or  deep  injections.  While  it  is  admitted  that  this  might  not  always 
be  true,  the  objection  to  disturbances  of  the  orbital  contents  is  one 
that  on  general  principles  should  require  careful  consideration  and 
absolute  certainty  of  its  necessity  before  being  undertaken. 

Buccal  Incision  for  Exposure  of  the  Nerve  at  the  Infra-orbital  Foramen. 
— External  scar  and  consequent  disfigurement  ma}'  be  avoided  by  an 
incision  through  the  mucous  membrane  and  periosteum  carried  down 
to  the  bone  in  the  region  of  the  canine  fossa,  the  periosteal  and  over- 
lying tissues  being  separated  from  the  bone  with  a  periosteotome. 
The  bone  surface  is  followed  up  to  the  infra-orbital  foramen,  which 
should  be  found  in  direct  line  above  the  interproximate  space  of  the 
bicuspid  teeth.  Variations  through  irregularities  of  the  teeth  or  upper 
jaw,  however,  render  such  guiding  lines  uncertain.  In  the  author's 
experience  it  has  been  found  safer  and  more  satisfactory  after  having 
separated  a  sufficient  periosteal  surface  to  insert  the  first  finger  and 
to  continue  the  periosteal  separation  by  pressure  in  this  way.  The 
same  finger  of  the  other  hand  serves  as  guide,  and  is  placed  over  the 
foramen,  which  can  usually  be  felt  from  the  external  surface  until  the 
nerves  and  vessels  as  they  pass  through  the  foramen  can  be  followed 
with  the  tip  of  the  finger  inserted  into  the  wound  from  within  the 
mouth.  With  the  finger  in  this  position,  as  shown  in  Fig.  133,  a  hook 
can  then  be  inserted  and  guided  into  place,  the  nerves  and  vessels 
caught  and  sufficiently  withdrawn  to  make  it  possible  to  grasp  them 
more  firmly  in  a  forceps.  By  making  tension,  a  sufficient  portion  of 
the  nerve  can  readily  be  resected  at  this  point.  Instead  of  resorting 
to  the  use  of  screws  or  metal  plugs  a  very  simple  and  satisfactory 
procedure  is  the  author's  modification  of  this  operation  as  usually 
performed.  It  has  proved  to  be  exceedingly  satisfactory  to  obliterate 
the  canal  by  enlarging  the  external  opening  with  a  bur  in  a  dental 
engine,  following  the  nerve  as  far  in  its  bony  canal  as  ma}^  be  safely  done 
without  risking  injury  to  the  contents  of  the  orbit,  and  by  freshening 
bony  surfaces  with  the  bur,  to  insure  new  bone  growth,  which  will 
completely  fill  and  block  the  external  opening,  thus  preventing  the 


264  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

likelihood  of  nerve  regeneration.  When  it  is  found  necessary  to  follow 
the  nerve  back  to  the  sphenomaxillary  fossa,  in  cases  where  the  internal 
opening  is  made,  this  is  best  done  by  opening  into  the  maxillary  sinus. 
Objection  to  this  is  made  by  some  authors  on  the  ground  that  there 
is  more  likely  to  be  infection  when  the  maxillary  sinus  is  opened. 
Therefore  the  external  opening  is  to  be  preferred.  This,  according 
to  the  author's  experience,  is  an  erroneous  view,  because  in  large 
numbers  of  jiatients  suffering  from  tic  douloureux  he  has  found  that 
the  maxillary  antra  were  enlarged  and  either  diseased  or  a  continued 
menace  in  ofi'ering  the  likelihood  of  irritation  in  that  region.  There- 
fore entirely  outside  of  the  question  of  neurectomy  it  is  frequently  a 
safeguard  to  have  the  maxillary  sinus  properly  opened  and  its  condition 


y- 

>*r^     i 

\w 

\ 

v. 

i 

4 

y   /tSff^Bi         \ 

\ 

^ 

^^^-^^1 

\ 

^ 

0 

f^    iH 

0^ 

^'''  ^ 

■i 

m-—^^^ 

Fig.   133. — Resection  of  the  second  division  of  the  fifth  nei've  at  the  infra-orbital  foramen 
through  an  intrabuccal  incision. 

definitely  ascertained.  Whenever  there  is  the  slighest  suspicion  of 
maxillary  sinus  trouble  he  believes  that  the  proper  method  is  to  open 
through  the  external  wall  of  the  sinus,  selecting  a  point  in  the  region 
of  the  canine  fossa  at  which  the  wall  may  be  found  to  be  most  yielding, 
and  extending  this  opening  until  the  entire  external  wall  of  the  maxil- 
lary antrum  has  been  removed.  In  enlarged  sinuses,  such  as  those 
usually  found  in  these  cases,  an  opening  of  this  kind  will,  in  most  cases, 
be  large  enough  to  admit  the  insertion  of  a  finger,  and  when  hemor- 
rhage has  been  checked  permit  a  good  view  of  the  floor  of  the  orbit. 
The  distance  from  the  upper  border  of  the  external  opening  to  the 
foramen  is  usually  very  slight,  and  therefore  exposure  of  the  nerves 
at  this  point  is  easily  accomplished.     Frequently  the  nerve  is  found 


SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA        265 

to  be  almost  completely  exposed  when  the  mucoperiosteal  lining  of 
the  antrum  has  been  removed.  These  are  the  cases  in  which  the  por- 
tion of  the  nerve  posterior  to  the  infra-orbital  canal  is  likely  to  suffer 
continued  irritation  after  resection  at  the  infra-orbital  foramen. 
They  are  also  the  ones  in  which  the  nerve  may  be  most  easily  followed 
back  in  the  direction  of  the  sphenomaxillary  fossa.  To  those  who  are 
accustomed  to  treat  the  maxillary  sinus  by  radical  operation,  this 
procedure  will  not  be  a  matter  of  serious  consideration.  The  danger 
of  infection  with  proper  care  is  not  significant.  The  ultimate  closure 
of  the  opening  without  external  deformity  is  assured,  and  the  danger 
of  future  disease  and  irritation  reduced  to  the  minimum.  Results  in 
the  author's  cases  have  been  exceedingly  satisfactory. 

Carnochan  reaches  the  nerve  at  the  foramen  rotundum  through 
the  maxillary  sinus  by  a  large  external  incision  which  joins  the  incision 
made  near  the  lower  orbital  border  at  the  infra-orbital  margin,  and  is 
extended  down  the  cheek  close  to  the  nose.  A  flap  is  reflected  down- 
ward and  upward  ahd  the  maxillary  sinus  opened  just  below  the  infra- 
orbital foramen.  He  follows  the  nerve  back,  trephines  the  posterior 
antral  wall  to  expose  the  sphenomaxillary  fossa,  and  through  this  con- 
tinues back^\'ard  to  the  foramen  rotundum,  where  the  nerve  is  twisted 
and  cut  with  cm-ved  scissors.  This  appears  to  be  unnecessarily  severe 
in  view  of  the  fact  that  removal  of  the  Gasserian  ganglion  may  after  all 
be  necessary  and  no  kind  of  peripheral  operation  sufficient. 

Third  or  Inferior  Maxillary  Division  of  the  Fifth  Nerve. — The  mental 
branch  can  be  readily  exposed  at  the  mental  foramen,  the  foramen 
enlarged  with  a  surgical  or  dental  engine  bur,  and  the  inferior  dental 
canal  exposed  as  much  as  may  be  necessary  to  give  opportunity  for 
resection  of  a  sufficiently  large  portion  of  the  nerve.  Cryer  has  called 
attention  to  the  fact  that  the  direction  of  the  nerve  at  its  exit  through 
the  mental  foramen  is  slightly  backward,  so  that  it  is  usually  impos- 
sible to  enter  the  inferior  dental  canal  with  a  probe  passed  through  the 
mental  foramen  in  a  backward  direction.  It  is  therefore  necessary  to 
enlarge  the  foramen  and  extend  the  opening  backward  along  the  line 
of  the  canal  until  a  sufficiently  clear  entrance  has  been  effected.  The 
nerve  may  be  grasped,  drawn  forward,  and  a  section  evulsed  according 
to  the  Thiersch  method,  or  a  long  flexible  dental  engine  drill,  especially 
made  for  the  purpose,  can  be  passed  into  the  canal,  and  its  nerve  and 
vessel  contents  cut  out  for  a  considerable  distance.  Sometimes  this 
can  be  done  almost  completely  to  the  angle  of  the  jaw  (Fig.  134). 

The  author  formerly  used  to  fill  the  inferior  dental  canal  after 
the  removal  of  the  nerve  with  a  gutta-percha  point  which  had  been 
softened  in  a  solution  of  gutta-percha  and  chloroform,  and  was  forced 
into  the  canal  after  controlling  hemorrhage  and  flooding  the  canal 
with  oil  of  eucahptus.  Such  a  gutta-percha  plug  was  found  to  offer 
no  resistance  to  healing  processes  which  took  place  upon  the  mucous 
membrane  surface  quite  promptly,  and  covered  the  gutta-percha  at  the 
foramen  completely.     But  in  the  course  of  time  the  gutta-percha  was 


266 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


eventually  thrown  out.  During  recent  years  he  has  adopted  a  modi- 
fication of  Garretson's  operation,  and  instead  of  endeavoring  to  remove 
a  section  of  the  nerve  through  an  enlarged  opening  at  the  mental 
foramen  and  filling  as  described,  he  has  carried  the  bur  back  from  one  to 
two  inches  and  removed  the  external  wall  of  the  canal.  This  portion  of 
the  nerve  is  of  course  entirely  destroyed  and  the  inferior  dental  canal 
practically  eliminated  as  the  result  of  a  complete  obstruction  of  the  canal 
by  new  growth  of  bone  and  connective  tissue.     If  the  source  of  irrita- 


FiG.   134. — Third  or  inferior  maxillary  division  of  the  fifth  nerve  exposed  at  the  mental 
foramen  and  the  inferior  dental  canal  opened  for  resection. 


tion  happens  to  be  in  the  anterior  portion  of  the  lower  jaw  this  operation 
will  be  effective.  But  if  situated  farther  back  the  result  will  naturally 
be  unsatisfactory.  In  some  cases  it  is  therefore  necessary  to  reach  this 
division  of  the  nerve  at  its  more  central  portion. 

The  nerve  may  be  reached  by  perforating  the  jaw  at  any  point 
along  the  line  of  the  inferior  dental  canal.  Cryer  has  suggested  en- 
trance through  the  ramus  of  the  jaw  by  deepening  the  sigmoid  notch 
until  the  nerve  is  reached  at  its  entrance  to  the  mandibular  foramen. 
To  accomplish  this  and  to  avoid  scarring,  the  incision  is  carried  down 


SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA       2G7 

along  the  posterior  border  of  the  jaw,  the  periosteum  separated  from 
the  bone  with  the  overlying  muscular  attachment  of  the  masseter,  and 
retracted  until  the  external  surface  of  the  ramus  is  exposed.  The  nerve 
may  be  divided  by  an  incision  within  the  mouth,  carried  through  down 
to  the  inferior  side  of  the  anterior  border  of  the  ramus,  separating  the 
pterygoid  muscles  and  periosteum,  which  are  forced  away  with  the 
periosteotome  and  finger  until  the  mandibular  foramen  can  be  felt. 
The  difficulty,  however,  in  attempting  this  operation  is  that  it  does 
not  give  the  best  opportunity  for  resection  of  a  sufficient  portion 
of  the  nerve.  In  the  recent  case  of  a  patient  in  whom  the  vessels  of  the 
mandibular  foramen  were  severed,  severe  hemorrhage  followed,  with 
tendency  to  recur  whenever  the  packing  was  removed.     This  has  con- 


FiG.  135. — Relation  of  the  inferior  dental  artery  to  the  inferior  dental  nerve  in  the  canal 
in  the  lower  jaw,  chiselled  open  for  operation.     Three-quarters  natural  size. 


vinced  the  author  that  whenever  an  operation  is  performed  which  is 
likely  to  involve  the  inferior  maxillary  artery  accidentally  or  otherwise, 
the  method  of  approach  should  be  such  as  to  offer  opportunity  for  direct 
control  of  the  vessel.  A  number  of  authors  advocate  trephining  the 
jaw  at  a  point  midway  between  the  anterior  and  posterior  border  of 
the  ramus  just  above  the  angle  of  the  jaw.  To  do  this  an  incision  is 
made,  as  recommended  by  Krause,  directly  through  the  skin,  masse- 
teric fascia,  masseter  muscle,  and  periosteum  to  the  bone.  The 
incision  may  also  be  carried  around  the  lower  border  of  the  jaw,  around 
the  angle  of  the  jaw,  dividing  the  skin  and  superficial  fascia,  isolating 
the  two  upper  branches  of  the  facial  nerve  and  Stenson's  duct.  After 
retraction,  the  incision  is  carried  through  the  masseter  muscle  down  to 
the  ascending  ramus  of  the  jaw  which  is  trephined  just  above  the  angle. 


268 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


The  nerve  is  grasped  with  forceps  and  followed  upward  for  an  inch 
and  divided.  By  either  incision  the  facial  nerve  has  to  be  avoided 
and  scarring  upon  the  external  surface  of  the  cheek  prevented.  The 
lingual  nerve  may  be  found  directly  under  the  mucous  membrane 
of  the  tongue  in  the  region  of  the  three  last  molar  teeth,  just  after  it 
has  entered  the  base  of  the  tongue  between  the  ramus  of  the  lower  jaw 
and  the  palatoglossal  arch.  The  mouth  is  opened  with  a  suitable  gag, 
the  tongue  pulled  to  the  healthy  side  and  upward,  the  mucous  mem- 
brane divided  at  a  point  just  anterior  to  the  lower  molar  tooth,  and  the 
incision  carried  from  before  backward  with  care  to  avoid  the  tongue. 
With  the  nerve  thus  exposed  a  portion  can  be  extracted  and  the  wound 
sutured  (Fig.  135). 


Fig.  136. — Exposure  of  the  second  and  third  branch  of  the  trigeminal  nerve  close 
to  the  foramen  rotundum  and  foramen  ovale  (Kronlein's  temporal  method) :  1,  turned-up 
skin  flap;  3,  turned-down  flap  of  zygoma  and  masseter;  3,  anterior  sawed  surface  of  the 
zygoma;  4<  posterior  sawed  surface  of  the  zygoma;  5,  turned-up  flap  of  coronoid  process 
and  temporal  muscles;  6,  cut  surface  of  the  coronoid  process;  7,  infratemporal  crest;  8, 
external  pterygoid  muscles;  9,  pterygoid  process;  10,  maxillary  tuberosity;  11,  sawed 
surface  upon  the  upper  jaw;  12,  sawed  surface  upon  the  zygomatic  process  of  the  temporal 
bone;  IS,  spinous  tubercle;  14,  superior  maxillary  nerve;  15,  palatine  nerve;  i^,  inferior 
maxillary  nerve  at  the  foramen  ovale. 


Extracranial  Operations  at  the  Base  of  the  Skull. — The  number  of 
these  operations  represent  almost  unlimited  modifications  of  Lucke's 
original  method,  which  included  osteoplastic  resection  of  the  malar 
bone  and  an  opening  through  the  sphenomaxillary  fossa  to  the  foramen 
rotundum.  Entrance  through  the  antrum  of  Highmore  has  already 
been  described.  The  incision  through  the  cheek  from  a  ]Doint  close 
to  the  angle  of  the  mouth  to  the  lobule  of  the  ear  is  carried  down  to  the 
buccinator  muscle,  but  cautiously  so  as  not  to  divide  the  mucous 


SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA       269 

membrane  of  the  mouth,  the  fibers  of  the  facial  nerve,  the  parotid 
gland,  and  Stenson's  duct  are  avoided,  the  intervening  bone  and  muscle 
structures  are  removed,  and  the  lingual  and  inferior  dental  branches 
located  and  traced  back  to  the  foramen  ovale.  Mikulicz  makes  an 
incision  from  the  mastoid  process  at  the  anterior  edge  of  the  sterno- 
mastoid  down  to  the  hyoid  bone  and  upward  and  forward  in  a  curve 
to  the  margin  of  the  lower  jaw  at  the  anterior  border  of  the  masseter 
muscle.  At  this  point  the  incision  is  carried  down  to  the  bone  of  the 
lower  jaw,  which  is  divided  behind  the  third  molar  tooth,  the  ramus 
is  turned  upward  and  the  body  of  the  jaw  pulled  forward,  and  the 
divided  dental  and  lingual  nerves  are  found  located  upon  the  internal 
pterygoid  muscle  which  has  been  separated  from  its  attachment. 
Of  all  the  operations  suggested,  the  most  important  seems  to  be 
Kronlein's  temporal  method  for  exposure  of  the  second  and  third 
branches  of  the  trigeminal  nerve  close  to  the  foramen  rotundum  and 
foramen  ovale  (Fig.  136). 

Removal  of  Gasserian  Gajiglion. — Operation  for  the  removal  of  the 
Gasserian  ganglion  should  be  resorted  to  under  the  following  con- 
ditions : 

1.  When  all  efforts  to  check  the  pain  by  medical  treatment  and  the 
correction  of  sources  of  peripheral  irritation  have  failed. 

2.  When  peripheral  operations  have  been  unsuccessfully  tried  for 
the  relief  of  pain,  apparently  confined  to  individual  branches. 

3.  When  all  the  branches  of  the  nerve  are  involved. 

4.  In  almost  every  case  it  should  supplant  operations  for  division 
at  the  base  of  the  skull.  When  the  gravity  of  operations  like  those 
described  for  reaching  the  foramen  ovale  and  the  foramen  rotundum  is 
considered,  the  greater  certainty  of  success  and  the  increasing  freedom 
from  danger  and  ill  effect  that  improved  technic  has  brought  about  in 
removal  of  the  ganglion  should  unquestionably  make  this  the  operation 
of  choice. 

In  1884  J.  Ewing  Mears,  of  Philadelphia,  first  recommended  the 
removal  of  the  Gasserian  ganglion  for  relief  of  major  neuralgia.  Pro- 
fessor Rose,  of  King's  College,  London,  first  performed  the  operation  in 
1890.  His  method  of  approach  was  by  trephining  the  base  of  the 
skull  beneath  the  ganglion  and  removing  it  with  a  curette.  Dr. 
Edmund  Andrews,  of  Chicago,  was  the  first  to  perform  this  operation 
in  America.  Gushing^  has  perfected  what  he  calls  the  transzygomatic 
route,  and  has  published  the  sketch  shown  in  Fig.  137,  which  at  once 
illustrates  and  describes  the  methods  of  approach.  Manj^  modifica- 
tions of  the  older  methods  have  been  suggested  by  Keen,  Frazier, 
Spiller,  Doyen,  Poirier,  Coelho,  and  other  surgeons.  Since  the  opera- 
tions most  often  performed  by  American  surgeons,  and  therefore  the 
ones  upon  which  most  of  our  evidence  of  success  depends,  are  the 
Hartley-Krause  and  the  Gushing,  it  seems  necessary  to  describe  only 
these  two. 

1  Jour.  Am.  Med.  Assn.,  April  28,  1900. 


270 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


Victor  Horsley^  resected  the  second  and  third  division  with  a  high 
temporal  opening  in  1900.  The  operation  known  as  the  Hartley- 
Krause  operation  was  devised  by  Krause,  and  first  performed  by 
Horsley  August  8,  1891,  and  by  Krause  February  23,  1892.  In  neither 
of  these  operations  was  the  ganghon  removed.  Only  the  second  and 
third  divisions  were  divided.  January  31,  1893,  Krause  removed  the 
ganglion  by  this  operation. ^ 

Krause  calls  attention  to  the  necessity  of  washing  out  the  eye  with 
boric  acid  solution  before  the  operation,  and  to  the  need  of  the  pro- 
tection of  the  eye.  This  he  accomplishes  by  the  use  of  a  large  unground 
watch-glass  held  in  position  with  a  zinc-oxide  adhesive  plaster. 


Fig.  137. — Cushing's  illustration  of  transzygomatic  route  in  removal  of  the  Gasserian 
ganglion.  Sketch  from  a  coronal  section  of  the  head,  schematizing  the  three  chief 
methods  of  approach:  Oblique  methods:  (1)  The  high  temporal  root  (Horsley  and 
Hartley-Krause) ;  (2)  the  low  or  pterygomaxillary  (Rose,  Andrews,  etc.).  (3)  Horizontal 
direct  method  transzygomatic  (Lexer,  Gushing,  etc.).  The  Doyen  method  demands  the 
space  included  by  all  three.     (Jour.  Am.  Med.  Assn.,  April  28,  1900.) 

Under  chloroform  anesthesia  the  incision  is  begun  just  anterior 
to  the  tragus.  It  is  "uterus-shaped,"  first  extending  upward,  then 
forward,  and  then  downward  with  base  of  flap  and  zygoma.  The 
base  of  the  zygoma  is  3  or  3.5  cm,  wide,  and  the  height  in  the  center  is 
6.5  cm.  The  greatest  width  is  5  or  5.5  cm.  This  incision  is  through 
all  of  the  tissues  down  to  the  base,  and  is  then  carried  through  the  bone 
by  means  of  a  circular  saw.  Sometimes  the  bone  is  removed,  but  is 
usually  preserved,  attached  to  its  periosteum,  forming  the  Wagner 
flap.     In  the  second  step  the  dura  is  separated  from  the  floor  of  the 


>  Practitioner,  September,  1903. 

2  Jour.  Am.  Med.  Assn.,  October  11,  1902,  p.  900. 


SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA       271 

fossa  to  the  foramen  si)inosiim,  and  the  brain  retracted  upward  only 
as  far  as  is  absohitely  necessary.  The  middle  meningeal  artery  is 
always  ligated,  usually  with  two  ligatures,  and  cut  between  them. 
In  the  third  step  the  hemorrhage  is  stopped  by  packing  gauze  between 
the  bone  and  the  retractor,  holding  the  brain  upward.  After  the 
hemorrhage  is  stopped  and  the  retractor  is  in  position,  work  with  the 
elevator  is  begun.  The  third  division  is  first  found  and  exposed,  and 
then  the  second.  The  dura  is  pushed  back  from  these  two  nerves  and 
from  the  ganglion,  and  the  three  structures  are  lifted  successfully 
from  the  base  (Fig.  13S). 


Brain  retractor. 


Dura  mate 


I-  Branch 


11.  Branch 


MiddLc  meningeal 
artery  {ligaied). 


III.  Bravch. 

Skin,  muscle,  and  bone-flap. 
Fig.   138. — Field  of  operation  to  remove  the  Gasserian  ganglion,  according  to  Krause. 


In  separating  the  dura  from  the  upper  surface  of  the  ganglion  it  may 
be  opened,  but  this  is  usually  of  no  importance.  The  third  division 
is  grasped  A^ith  Pean  forceps  and  lifted  upward.  The  first  division  is 
not  exposed  at  any  time  during  the  operation,  except  at  its  junction 
with  the  ga^iglion,  because  of  its  position  in  the  wall  of  the  cavernous 
sinus  and  its  proximity  to  the  third,  fifth,  and  sixth  nerves. 

After  isolation  of  the  ganglion  it  is  grasped  with  forceps  at  its  junc- 
tion with  the  sensory  root;  the  second  and  third  divisions  are  cut  off 
at  their  exit  from  the  foramina,  and  the  sensory  root  is  twisted  out  by 
means  of  the  attached  forceps.  It  is  sometimes  taken  off  at  the  pons. 
The  first  division  usually  tears  off  close  to  the  ganglion.  The  ends 
of  the  nerves  are  pushed  down  into  their  foramina;  the  retractor  is 
removed  and  the  flap  brought  into  position.     So  far  the  motor  root 


272 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


has  not  been  separated  from  the  gangHon  in  the  performance  of  the 
operation,  but  experiments  have  shown  that  it  may  be  possible  to 
do  it. 

Cushing's  operation,  as  shown  in  his  illustration  (Fig.  137),  is  some- 
what lower  than  the  Hartley-Krause.  The  U-shaped  incision,  with 
its  base  directed  downward,  is  made  between  the  eye  and  the  ear,  with 
its  upper  part  slightly  above  the  center  of  the  zygoma,  the  lower  points 
a  little  below.  The  zygoma  is  divided  at  each  end  and  turned  down 
with  the  flap.  The  incision  is  carried  through  the  temporal  muscle 
to  the  temporal  bone,  which  is  separated  from  its  attachments,  includ- 
ing the  periosteum,  in  such  a  manner  as  to  expose  the  lower  portion 
of  the  temporal  fossa  down  to  the  attachment  of  the  external  pterygoid 
muscle  below  the  temporal  crest.     An  opening  is  then  made  with  a  tre- 


Xv>"''  ■    2 


Fig.  139. — Gasserian  ganglion,  with  its  roots  enlarged;  a,  external  view;  1,  small 
motor  root;  2,  large  sensory  root;  S,  semilunar  ganglion,  over  which  the  motor  root 
passes  to  get  to  the  third  branch;  4,  first  branch;  5,  second  branch;  6,  third  branch. 
(After  Riidinger,  Bull-von  Bergmann.) 


phine  and  enlarged  until  it  is  about  3  cm.  in  diameter.  The  middle 
meningeal  artery  is  avoided  by  continuing  the  operation  in  a  slightly 
anterior  direction.  The  dura  is  elevated  to  expose  the  foramen  ovale 
and  its  elevation  continued  until  the  foramen  rotundum  is  reached. 
Division  of  the  commissure  of  the  under  layer  of  the  dura  admits  of 
its  being  gently  raised  from  the  ganglion  back  to  the  sensory  root.  The 
ganglion  is  then  elevated,  freed  from  its  attachment  to  the  dura,  and 
the  first  branch  of  the  nerve  is  separated  with  care  to  a^^oid  the  caver- 
nous sinus.  The  three  peripheral  branches  are  then  elevated  with 
blunt  hooks  and  sutured  close  to  the  foramen,  the  ganglion  grasped 
with  forceps  and  evulsed.  The  parts  are  replaced,  and  held  in  position 
with  suture  without  drainage  (Fig.  139). 

The  effect  of  the  removal  of  the  Gasserian  ganglion  as  evidenced 
by  altered  sensation  is  shown  by  Figs.  140  to  143. 


SURGICAL  METHODS  OF  TREATMENT  IN  NEURALGIA       273 

MortaUty. — In  100  cases  collected  by  Tiffany^  the  mortality  rate 
was  22  per  cent.;  in  a  second  series  of  100  cases  reported  by  Carson^ 
the  mortality  was  11  per  cent.  Most  of  these  operations  were  accord- 
ing to  the  ITartkn-Krause  method.  ]\Iurphy  and  Xeff's  report  of  42 
cases  with  (>  deaths,  which  is  here  given  because  of  its  valuable  record 


Fig.  140. — Scheme  sho^-ing  effects  of  total  extirpation  of  Gasserian  ganglion  forty- 
seven  days  after  operation.  Sensation  of  heat  spoken  of  as  slightlj'  warm;  sensation  of 
cold  absent.  Ti,  Fs,  T^3,  first,  second,  and  third  branches  of  fifth  nerve;  oma,  occipitalis 
major;  omi.  occipitalis  minor;  am,  auricularis  magnus;  cs,  subcutaneous  coU       (Friedrich.) 

WvM^        Zone  of  absolute  aiiiesthesJa  and  analgesia;  complete  loss  of  temperature  area 


D 
D 


Zone  of  nearly  eoniplete  aniesthesia  and  analgesia. 

Zone  of  distinct  Ijut  diminished  hypalgesia  and  hyperitstliesia. 

Area  of  normal  sensation. 

Outline  of  innervation  zones  of  trigeminal. 


of  other  operative  aspects  as  well  as  mortality,  shows  about  15  per 
cent.  Gushing  reports  20  cases  of  his  own  operated  upon  according 
to  his  own  method,  with  a  mortality  of  5  per  cent.  The  steadily 
improving  mortality  rate  under  improved  operations  and  technic  is 
encouraging. 


1  Annals  of  Surgery,  1896,  xxiv,  575. 

2  Med.  Re\dew,  St.  Louis,  1899,  xxxix,  199. 


18 


274  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


Fig.  141 

Zone  of  absolute  anesthesia  and  analgesia.     iSixty-three  days  later  than  in 
Fig.  140.     (After  Bull- von  Bergmann.) 


Fig.  142 


^^/  Zone  of  hypalgesia  and  hyperesthesia.     Sixty-three  days  later  than  in  Fig.  141 , 

^^  (After  Bull-von  Bergmann,') 


DENTAL  ASPECT  OF  TRIGEMINAL  NEURALGIA  275 

The  records  of  42  cases  gathered  by  IVIurphy  and  Neff  (see  pages 
276  to  279  are  given  in  detail  because  these  cases  appear  to  show  the 
best  possible  data  upon  which  to  base  judgments  of  manj^  features  of 
operative  results  as  well  as  the  question  of  mortality. 

Later  reports  by  Cushing  of  over  100  cases  ^^"ith  almost  no  mortality, 
and  the  results  obtained  by  Frazer  and  many  other  operators  who 
have  folloA\ed  the  impro^'ed  methods  of  these  two  operators,  have 
reduced  the  question  of  mortality  almost  to  a  negligible  factor.  Never- 
theless, the  ease  and  safety  of  alcoholic  injections  still  warrant  the 
employment  of  this  treatment  before  the  more  radical  Gasserian 
operations  are  resorted  to.  It  is  even  possible  that  alcoholic  injections 
of  the  Gasserian  ganglion  may  be  found  to  be  entirely  sufficient. 


Fig.   143. — Photograph  taken  on  the  tenth  day  after  operation.      (Cushing.) 

THE  DENTAL  ASPECT  OF  TRIGEMINAL  NEURALGIA. 

The  dental  and  oral  aspect  of  trigeminal  neuralgia  is  generally 
conceded  to  be  a  matter  of  great  importance.  Many  vital  features, 
however,  are  but  little  appreciated,  and  there  is  much  confusion 
in  the  views  of  dentists,  oral  and  general  surgeons,  and  practitioners 
of  other  divisions  of  medicine  in  regard  to  the  importance  and  the 
character  of  the  effect  of  local  influences  in  the  region  of  the  mouth. 
In  the  description  of  real  or  fancied  effects  from  treatment  or  removal 
of  teeth,  dentists  have  made  exaggerated  and  often  unscientific  claims 
and  have  done  much  to  destroy  the  confidence,  particularly  of  those 
who  believe  in  the  more  or  less  definite  pathological  principles  which 
govern  all  divisions  of  the  body  as  affected  by  various  forms  of  disease. 
On  the  other  hand,  only  those  who  are  familiar  with  diseases  of  the 
teeth  and  their  treatment  could  be  expected  to  diagnosticate  or  fully 
understand  dental  irritation.  As  a  result,  the  importance  of  the  mouth 
and  the  effect  of  its  deformities  and  diseases  is  both  underestimated 
and  overestimated  in  its  relation  to  the  etiology  of  trigeminal  neuralgia. 


276 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


Operator  and 
reference. 

Date  of  opera- 
tion. 

Dura- 
tion of 
disease. 
Years. 

Sex, 
age, 
side. 

Previous  operations. 

1 

Bartlett,    Willard,    Ann. 

October  10, 

17 

Female, 

All  teeth  removed  15  years 

Surg.,  June,  1901,  p.  683 

1900 

60  years, 
left 

previous;    infra-orbital 
evulsed,  1898. 

2 

Bartlett,    Willard,    Ann. 

November  27, 

Many 

Female, 

All  teeth  removed. 

of  Surg.,  June,  1901,  p. 

1901 

50  years. 

683 

right 

3 

Beck,  Carl  (Chicago),  per- 

November, 

4 

Male, 

Third  div.  resected  2  years 

sonal  communication 

1897 

48  years, 
left 

ago;  second  div.  Ij  years 
ago. 

4 

Ibid. 

May,  1899 

10 

Male, 

42  years, 

left 

Fourteen  previous  opera- 
tions; all  possible  methods 
from  neurectomy  to  re- 
moval of  bone. 

5 

Ibid. 

October, 

i 

Male, 

Three    previous    operations: 

1899 

60  years, 
right 

1,  removal  of  cyst  of  face; 

2,  neurectomy  of  first  div.; 

3,  neurectomy  of  first  and 
second  divisions. 

6 

Ibid. 

December  10, 

Several 

Male, 

Neurectomy    of    second    di- 

1900 

68  years, 
right 

vision,  neurectomy  of  third 
division. 

7 

Coelho,     S.,     Revue     de 

February  28, 

6 

Female, 

Infra-orbital      resection      in 

Chir.,    Paris,    May    10, 

1898 

40  years. 

1894;      inferior     maxillary 

1899 

right 

in  1895. 

8 

Gushing,    Harvey,    Jour. 

August,  1899 

10 

Male, 

Infra-orbital  evulsed  in  1896, 

Am.   Med.   Assn.,   April 

63  years. 

inferior   dental   in    1897. 

28,  1900 

right 

9 

Ibid. 

December, 
1899 

12 

Male, 

55  years, 

right 

Infra-orbital  evulsed  in  1892. 

10 

Ibid. 

January,  1900 

2 

Male, 
38  years 

Infra-orbital  and  inferior 
dental   evulsed   in    1899. 

11 

Ibid. 

January,  1900 

7 

Female, 

60  years, 

left 

Infra-orbital  evulsed  in  1897 
and  1899. 

12 

Erdmann,   J.   F.,    N.   Y. 

August  8, 

4 

Male, 

Supra-orbital,  supratrochlear 

Med.  Jour.,  May  6,  1899 

1898 

53  years, 
left 

and  infra-orbital  nerves  ex- 
cised in  1897. 

13 

Halstead,  A.  E.,  personal 

November  9, 

6 

Male, 

None. 

communication 

1900 

53  years, 

right 
Female, 

14 

Ibid. 

March  3, 

7 

Inferior     maxillary     divided 

1901 

57  years, 

left 

Male, 

2  years  before. 

15 

Ibid. 

May  12, 

10 

None. 

1901 

50  years, 
left 

16 

Krause,  F.,  Munch,  med. 

March  24, 

12 

Female, 

Resection  of  first  and  second 

Woch.,     June     25,     27, 

1899 

41  years. 

divisions  in   1898. 

February  9,  1901 

right 

17 

Ibid. 

August  26, 

10 

Male, 

Resection  of  second  division 

1899 

63  years, 
left 

twice. 

18 

Ibid. 

November  2, 

Female, 

Second   and   third   divisions 

1899 

59  years, 
right 

resected  in  1896. 

19 

Ibid. 

January  23, 

8 

Female, 

Liicke-Braun    of    1898;    re- 

1900 

44  years, 

right 
Female, 

mained  during  next  preg- 

20 

Ibid. 

February  23, 

Several 

nancy. 
Second   and   third   divisions 

1900 

58  years, 

left 
Female, 

operated  upon  many  times. 

21 

Ibid. 

May  7, 

4 

Four    previous    operations; 

1900 

30  years, 
left 

infra-orbital    resected. 

22 

Ibid. 

June  13, 

17 

Male, 

Infra-orbital  resected  in  1888; 

1900 

46  years, 
right 

second  division  reseated  in 
1892. 

23 

Ibid. 

August  27, 

7 

Female, 

Infra-orbital,       auriculotem- 

1900 

50  years, 
left 

poral  and  inferior  dental 
nerves  resected. 

24 

Ibid. 

August  29, 

15 

Female, 

First    and    second    divisions 

1900 

65  years, 
right 

resected  in  1898;  no  relief. 

25 

Ibid. 

March,  1901 

8 

Female, 

60  years, 

right 

Second  division  resected  in 
1898;  pain  recurred. 

DENTAL  ASPECT  OF  TRIGEMINAL  NEURALGIA 


277 


Method  used. 


Result. 


Immediate. 


Final. 


Remarks. 


Gushing 

Gushing 

Hartley-Krause 


Hartley-Krause, 
with  removal  of  bone 


Ibid. 

Ibid. 

Temporal  method 
Hartley-Krause 

Gushing 

Gushing 

Gushing 
Gushing 

Hartley-Krause 

Gushing,  modified 
by  Hartley 

Ibid. 

Ibid. 
Hart  ley-Krause 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 
Hartley-Krause 


Recovery 
Recovery 
Recovery 
Recovery 


Death     54     hours 
after  operation 


Recovery 
Recovery 
Recovery 


Paralysis  of  3d,  4th,  Slight  corneal  ulcer,  which 
and  bth  nerves,  4  soon  healed,  followed  opera- 
weeks;       recovered  tion. 

Eye     palsies     as     in  Xo  corneal  ulceration, 
above;  recovery 

Recovery 


Recovery 


Recovery 
Recovery 

Recovery 

Recovery 

Recovery 

Death  5  days 
after  operation 

Recovery 

Failure 

Recovery 

Recovery 


Death  6  hours 
after  operation: 
collapse 

Recovery 


Recovery 
Recovery 
Recovery 
Recovery 


Recovery 

Recovery 

Recovery 

Recovery 

Recovery 
Recovery 

Recovery  from 
pain 

Recovery 
Recovery 

Recovery ;  pain  in  left 
side  later 

Failure 
Recovery 
Recovery 


Garcinoma  of  parotid;  opera- 
tion undertaken  to  relieve 
pain  without  hope  of  radical 
cure. 


Results    learned    by    personal 
communication. 


Recovery 

Recovery 

Recovery 

Recovery 

Death  in  21  days: 
cardiac  disease  and 
pneumonia 


Eye  lost  7  weeks  after  opera- 
tion from  ulceration. 

Ankylosis  of  jaw  followed  oper- 
ation. 


Developed    suppurative    men- 
ingitis ;  had  chronic  nephritis. 


Pain  was  not  confined  to  left 
side  before  operation;  lesion 
evidently  central. 


Had    chronic    nephritis. 


278 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


Operation  and 
reference. 

Date  of  opera- 
tion. 

Dura- 
tion of 
disease. 
Years. 

Sex, 
age, 
side. 

Previous  operations. 

26 

Ibid. 

June  6, 

7 

Male, 

Infra-orbital      resected      in 

1901 

64  years, 

left 

Male, 

1894;  pain  recurred. 

27 

Ibid. 

June  17, 

25 

Second   division   resected  in 

1901 

63  years, 
left 

1893;  third  division  in  1895. 

28 

Keen,  W.  W.,  Jour.  Am. 

Two    opera- 

i 

Male, 

Infra-orbital      removed      in 

Med.    Assn.,    April    28, 

tions 

32  years. 

November,  1899. 

1900 

November  9, 
1899 

left 

29 

Levings,  A.  H.,  personal 

October  24, 

9 

Female, 

Infra-orbital  nerve  removed 

communication 

1900 

41  years, 
right 

in  1898. 

30 

Mammen,     E.,     personal 

November  20, 

2 

Male, 

communication 

1894 

56  years 

31 

Murphy,  J.  B. 

November  5, 
1898 

9 

Male, 

59  years, 

right 

Dental  operations  only. 

32 

Murphy,  J.  B. 

November  25, 
1899 

8 

Female, 

43  years, 

right 

33 

Murphy,  J.  B. 

October  5, 
1899 

7 

Male, 

67  years, 

right 

Dental  operations  only. 

34 

Murphy,  J.  B. 

October  31, 
1899 

4i 

Female, 

51  years, 

right 

35 

Murphy,  J.  B. 

April  15, 
1899 

2i 

Male, 

66  years, 

right 

Dental  operations  only. 

36 

Murphy,  J.  B. 

May  30, 

4 

Male, 

Second  division   of  fifth  re- 

1900 

50  years, 
left 

sected  August  8,  1899;  no 
pain  for  8  months. 

37 

Murphy,  J.  B. 

June  15, 
1901 

J 

Male, 

44  years, 

right 

38 

Renton,  J.  C,  Brit.  Med. 

November, 

7 

Male, 

Jour.,  November  17, 1900 

1898 

57  years, 
left 

39 

Same  as  above 

August,  1899 

5 

Female, 

67  years, 

right 

Male, 

Inferior  dental  excised;  pain 
returned  in  3  months. 

40 

Spellisy,   J.   M.,   Ann.   of 

July  19, 

9 

Several  teeth  removed  also 

Surg.,   1900,   vol.   xxxi 

1899 

55  years, 
right 

infra-orbital  and  inferior 
dental  nerves  in  1895  and 
1896. 

41 

Thomas,   J.    Lynn,    Brit. 

February  9, 

3 

Male, 

Teeth  extracted. 

Med.  Jour.,  October  28, 

1899 

34  years. 

1899 

right 

42 

Williams,    N.    T.,    Phila. 

September  2, 

More 

Female, 

Nerves     divided     in     1893; 

Med.  Jour.,  August  10, 

1899 

than 

38  years, 

teeth     extracted,     superior 

1901 

8 

right 

maxillary  ganglion  removed 
in  1894;  inferior  maxillary 
resected  in  1896;  intra- 
cranial resection  of  nerves 
August  30,  1899. 

Judging  from  long  years  of  experience  in  dealing  with  the  special 
or  at  least  unusual  affections  observed  in  a  practice  limited  to  diseases 
and  deformities  of  the  mouth  and  jaws,  and  from  a  wide  observation 
of  cases  noted  in  clinics  and  reported  by  others,  the  author  has  ven- 
tured upon  the  following  classification  of  pathological  conditions  of 
the  mouth  which  he  hopes  may  serve  to  distinguish  the  affections 
capable  of  inducing  long-continued  painful  forms  of  peripheral  irrita- 
tion, and  thus  becoming  factors  of  first  importance  in  causing  tri- 
geminal pain  of  neuralgic  character,  from  those  that  are  not,  which, 


DENTAL  ASPECT  OF  TRIGEMINAL  NEURALGIA 


279 


Method  used. 


Immediate. 


Result. 


Final. 


Remarks. 


Hartley-Krause  Recovery  Death  on  20th  day; 

'  coma 

Hartley-Krause  Recovery  Recovery 

Hartley-Krause  No  improvement  Pain  continued 


Grayish  patch  of  softening  at 
base  due  to  pressure  from 
retractor. 

Sclerotic  middle  meningeal  torn. 


Endothelioma     involving     the 
Gasserian  ganglion. 


Hartley-Krause 

Recovery 

Recovery 

Hartley-Krause 
Hartley-Krause 

Recovery 

Death;    November 
13,  1898 

Recovery 

Entire  ganglion  not  removed; 
second  division  between  gan- 
glion and  foramen  caught  by 
forceps  and  evulsed ;  complete 
relief  resulted. 

Hartley-Krause 

Recovery 

Recovery 

Hartley-Krause 

Death;  meningitis; 
October  22,  1899 

Hartley-Krause 

Recovery 

Recovery 

Hartley-Krause 

Death;    April    17, 
1899 

Hartley-Krause 

Recovery 

Recovery 

Hartley-Krause 

Recovery 

Recovery 

Hartley-Krause 

Recovery 

Recovery 

Hartley-Krause 

Recovery 

Recovery 

Hartley-Krause 
preliminary  ligation 
of  external  carotid 

Recovery 

Recovery 

Hartley-Krause 

Recovery 

Recovery 

Hartley-Krause 

Recovery 

Recovery 

Curetted    out    ganglion. 

however,  may  be  serious  enough  in  themselves.  It  is  further  hoped 
that  the  simple  but  essentially  practical  methods  of  diagnosis  may  also 
be  generally  helpful. 

Development  Factors. — A  study  of  the  embryonic  sections  and  other 
illustrations  (pages  547,  548,  559  and  566)  clearly  demonstrates  that 
arrested  development  or  restricted  growth  from  any  cause  in  the  region 
of  the  mouth,  the  most  common  evidences  of  which  are  found  in  high, 
narrow  p  alatal  vaults,  contracted  dental  arches,  and  irregular  teeth,  is 
chiefly  an  expression  of  abnormal  developmental  tendencies.    These 


280  NERVOUS  SYSTEM  AXD  THE  BUCCAL  REGION 

defects  are  usually  indicative  of  neurotic  tendency  and  therefore  of 
predisposition  to  painful  as  well  as  other  neuroses.  ^loreover,  such 
restricted  growth  invariably  manifests  itself  by  alterations  in  the  form 
of  surrounding  structures.  This  is  noticeably  true  of  the  general  form 
and  character  of  the  maxillae.  Corresponding  deviations  from  the 
normal  are  likely  to  occur  in  the  maxillary  and  other  closely  related 
cavities,  foramina,  and  canals,  and  the  passage  of  nerves  through  such 
abnormal  openings  subjects  them  to  irritation.  Xasal  defects,  such 
as  narrow  nares,  de^'iated  septa,  spurs,  and  hypertrophic  and  other 
pathological  alterations  of  structure,  are  similarly  frequent  evidences 
of  perverted  development.  A  more  detailed  description  of  these  con- 
ditions is  given  on  page  546.  Direct  opportunity  is  thus  offered  for 
diseased  conditions  of  the  nose  and  associated  parts,  including  the 
ethmoidal,  sphenoidal,  and  maxillary  sinuses  and  cells,  as  well  as  the 
orbital  and  aural  regions.  Through  any  of  these  the  nerves  may  be 
involved  in  the  disease  itself  or  become  affected  by  actual  alteration  in 
size  or  form.  Anomalous  communicating  openings  and  channels  may 
also  favor  pathological  states.  ]\Ian\'  branches  of  the  fifth  nerve  are 
thus  exposed  to  disease  or  more  or  less  direct  irritation.  Oral  deform- 
ity or  perverted  maxillary  development  can  unquestionably  so  change 
the  shape  of  the  orbits  that  the  adjustment  of  its  contents  to  their 
bony  encasement  may  cause  visual  defects  \^'hich  may  also  be  etiological 
factors  of  no  small  significance. 

Disease  of  the  middle  ear  through  Eustachian  infection,  the  cause 
and  effect  of  which  is  well  understood,  and  the  pressure  of  crowded 
teeth  incident  to  arrested  growth  of  the  jaw  frequently  cause  irritation 
of  the  nerve.  The  effect  of  tooth  grinding  and  jaw  clinching  in  pro- 
ducing nerve  exhaustion  or  irritation  is  described  below. 

The  reflection  of  restricted  growth  in  the  maxillary  region  as  affecting 
other  bones,  gives  at  least  a  reasonable  ground  for  belief  that  by 
arrested  or  perverted  development  in  infancy,  important  foramina 
at  the  base  of  the  skull,  notably  the  foramen  ovale  and  the  foramen 
rotundum,  through  which  the  vessels  and  nerves  emerge,  may  also  be 
sufficiently  restricted  in  size  or  altered  in  form  to  favor  pressure  upon 
the  nerve  when  for  any  reason  the  accompanying  vessels  may  become 
distended. 

This  is  worthy  of  due  consideration,  since  the  premonitory  signs 
often  appear  for  all  the  foregoing  conditions  at  such  an  early  age  and 
the  remedy  at  this  stage  is  so  simple. 

BUCCAL  CONDITIONS  WHICH  MAY  EXERT  PREDISPOSING 

OR  EXCITING  INFLUENCES,  THEIR  DIAGNOSIS 

AND  CORRECTION. 

Jaw  Clinching  and  Tooth  Grinding. — Almost  without  exception  the 
grinding  surfaces  of  the  teeth  of  patients  suffering  from  trigeminal 
affections  show  marked  evidence  of  the  effect  of  this  habit.     This 


TOOTH  GRINDING  281 

usually  makes  it  possible  to  diagnosticate  the  tendency  to  pain  even 
without  knowledge  or  history  of  the  case.  Cause  and  effect  are, 
however,  so  closely  interwoven  that  it  is  practically  impossible  to 
differentiate  between  the  two  with  sufficient  certainty  and  exactness 
to  warrant  definite  distinctions.  This  may  be  better  understood  by 
the  explanation  that  tooth  grinding  and  the  disturbed  rest  which  is 
associated  with  this  habit  may  be  caused  by  eye-strain,  whether  due  to 
astigmatic  or  other  visual  defects,  fatigue  from  long-continued  use, 
nervous  states  induced  by  auto-intoxication  or  other  toxic  effects, 
neurasthenia,  and  similar  nervous  conditions.  On  the  other  hand, 
given  any  local  or  general  excitant  which  may  give  rise  to  the  habit 
of  grinding  or  clinching  the  teeth  at  night,  and  we  have  at  once  a  factor 
capable  of  exercising  most  potent  influences  in  the  production  of  pain 
in  the  head  in  a  number  of  different  ways. 

1.  The  continued  activity  of  the  muscles  of  the  jaws  prevents  per- 
fect rest  and  is  fatiguing  in  much  the  same  sense  as  eye-strain,  with  this 
difference,  however,  that  the  ocular  muscles  are  usually  only  active 
when  the  eyes  are  in  use,  whereas  activity  of  the  jaw  muscles,  when 
the  habit  is  fully  formed,  continues  both  day  and  night.  Relief  of 
pain  and  prompt  increase  in  weight  and  improvement  of  general  health 
in  patients  for  whom  this  trouble  has  been  relieved  by  treatment, 
and  the  use  of  an  appliance  as  described  on  pages  290  and  291  has 
shown  this  to  be  a  factor  of  no  small  importance,  whether  primary  or 
secondary. 

2.  The  continued  overuse  of  the  teeth  in  this  way  gives  rise  to  cer- 
tain changes  in  the  pericementum,  the  vessels  and  the  nerves  surround- 
ing the  apical  ends  of  the  roots  of  the  teeth  involved,  and  the  cementum 
of  their  roots.  This  may  be  in  the  nature  of  a  chronic  pericemental 
hyperemia,  which  is  the  natural  result  of  ischemia  caused  by  forcing 
blood  out  of  the  vessels  of  the  pericementum  during  the  active  pressure 
that  is  made  upon  the  teeth,  and  the  consequent  hyperemia  which 
follows  the  relief  of  this  pressure.  This  congestion  can  and  does  cause 
pressure  upon  the  nerve  filaments  as  they  pass  from  the  end  of  the  root 
of  the  tooth  to  join  the  main  branch  of  the  nerve,  which  in  neurotic 
individuals  is  amply  sufficient  to  set  in  motion  very  serious  painful 
conditions. 

Pericementitis.— In  the  acute  form  pericemental  inflammation  gives 
rise  to  pain  which  is  frequently  referred  to  other  parts.  The  chronic 
forms,  however,  are  alone  significant  in  relation  to  neuralgia,  and  these 
only  rarely,  if  at  all,  because  of  the  effect  that  the  tendency  to  culminate 
either  in  pericemental  abscess  or  interstitial  gingivitis  prevents  the 
continuous  persistent  form  of  irritation  that  is  necessary  for  chronic 
reflex  nervous  manifestations. 

Hypercementosis.^ — Hypercementosis,  or  thickening  of  the  perice- 
mentum surrounding  the  end  of  the  root  by  involving  nerve  fibers  or 
by  pressure  upon  surrounding  nerve  structures  due  to  enlargement 
as  this  abnormal  growth  proceeds,  is  also  a  cause  of  pain. 


282  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Ankylosis. — Perhaps  the  most  serious  of  all  pathological  changes 
that  take  place  in  the  structures  surrounding  the  roots  of  the  teeth 
as  a  result  of  this  tooth-grinding  habit  is  the  tendency  of  the  roots  of 
such  teeth  to  become  ankylosed.  This  belief  is  confirmed  by  a  very 
large  number  of  patients  of  the  author,  the  crowns  of  whose  teeth  were 
abraded  and  worn  in  evidence  of  long  years  of  tooth  grinding.  Their 
histories  described  pain  of  various  kinds  m  the  distribution  of  the  fifth 
nerve,  particularly  periodical  headaches.  When  effort  was  made  to 
extract  such  teeth,  large  masses  of  alveolar  process  came  away  with 
the  roots.  Cross-sections  of  these,  made  by  decalcification  and  cut- 
tings from  microscopic  slides,  disclosed  the  condition  of  ankylosis  as 
shown  by  Fig.  144.     With  the  disappearance  of  the  pericementum  as 


Fig.  144. — Ankylosis  of  tooth  root.     Cross-section,  showing  root  and  attached  alveolar 
process  in  case  of  chronic  trigeminal  neuralgia. 

the  encroachment  of  bone  proceeds  in  the  process  of  the  development 
of  the  ankjdosis,  there  appears  to  be  constriction  of  the  little  nerve 
fibers  which  during  the  periods  of  the  attack  appear  to  be  capable  of 
giving  rise  to  the  most  excruciating  exacerbations  of  pain. 

Diseases  of  the  Dental  Pulp.— Pulpitis.— The  dental  pulp  is  so 
richly  supplied  with  nerves  and  bloodvessels,  and  by  its  very  nature 
so  highly  susceptible  to  vasomotor  stimuli,  that  enmeshed  as  these 
vessels  are  in  connective  tissue,  the  whole  being  surrounded  by  unyield- 
ing walls  of  dentin,  its  possibilities  for  gi^'ing  rise  to  pain,  and  particu- 
larly pain  of  reflex  character,  are  very  great.  Fortunately  the  ten- 
dency of  an  acute  circumscribed  pulpitis  is  rapidly  to  become  diffuse 


DISEASES  OF  THE  DENTAL  PULP  283 

and  pass  to  the  stage  where  strangulation  of  the  ner\-e  by  vascuUir 
pressure  causes  its  devitaHzation,  and  through  infection  the  formation 
of  pus  leads  to  dento-alveolar  abscess.  Although  the  process  is  often 
an  exceedingly  painful  one  throughout,  its  natural  time  limitation  is 
such  as  to  preclude  the  likelihood  of  its  becoming  a  factor  in  causing 
chronic  neuralgia  in  any  form.  There  are,  however,  certain  pulp 
degenerations  which  result  from  chronic  pulpitis,  long-continued 
irritation,  and  constitutional  influences,  or  toxic  effects  in  which  no 
outward  manifestation  is  given.  Pulps  under  these  conditions  often 
retain  vitality  for  many  years,  and  may  give  rise  to  reflex  pain  of 
almost  any  character.  Because  of  the  absence  of  the  usual  appearance 
of  diseased  teeth,  and  as  there  frequently  are  no  carious  ca^•ities  nor 
outward  signs  of  disease,  their  etiological  importance  is  quite  generally 
overlooked  in  diagnosis.  Atrophy,  fibroid,  calcareous  and  other  forms 
of  degeneration,  pulp  nodules,  and  pulp  tumors  are  vicious  degenerative 
forms  which  affect  pulps  of  teeth  with  a  frequency  not  fully  appre- 
ciated because  not  always  detected.  Each  of  these  conditions  has 
repeatedly  been  found  associated  with  trigemmal  neuralgia  that  has 
disappeared  or  been  markedly  benefited  by  treatment  of  the  pulp 
canals  or  removal  of  the  teeth. 

Pulp  Nodules.— Pulp  nodules  (Fig.  145)  are  undoubtedly  present 
in  the  pulps  of  many  persons  who  sufi'er  no  inconvenience  by  reason 
of  the  fact.  When,  however,  there  is  individual  predisposition  to 
nerve  disturbance  or  the  presence  of  an  excitant  sufficient  to  induce 
hj-peremia,  the  activity  of  the  bloodvessels  of  such  a  pulp  is  insufficient 
to  allow  reaction  in  relief  of  temporary  engorgement  with  the  same 
rapidity  as  the  vessels  of  a  pulp  not  so  aft'ected.  The  hard  substance  of 
the  pulp  stone  forced  against  the  nerve  fibers  through  counter-pressure 
of  the  unyielding  dentinal  walls  of  the  pulp  chamber,  does,  as  might 
be  ex-pected,  give  rise  to  excruciating  exacerbations  of  pain.  In  the 
absence  of  infection  or  traumatic  injury  such  pulps  may  remain  alive 
for  many  years,  in  fact  ahnost  indefinitely,  their  h}T)eresthetic  con- 
dition becoming  worse  as  time  goes  on.  This  is  the  condition  found 
so  often  in  association  with  tic  douloureux  (Figs.  146  and  147).  The 
adventitious  growth  of  dentin  upon  the  dentinal  pulpal  walls  may 
cause  similar  constriction  and  pain. 

It  must  be  understood  that  the  foregoing  cannot  be  relied  upon 
as  absolute  indications  that  the  first  cause  is  in  the  teeth.  Some  of 
these  symptoms  are  also  found  when  the  primary  etiological  factor^  is 
elsewhere,  and  are  s}Tnptomatic  of  brain  and  other  aft'ections.  For 
many  years,  howe^'er,  they  have  served  to  point  the  ^^•ay  in  large 
numbers  of  the  author's  patients,  and  have  often  helped  to  bring  about 
the  relief  which  has  been  given.  On  this  account  their  importance 
cannot  well  be  overestimated,  recommended  as  they  are  by  directness 
and  simplicity  as  well  as  the  possibility  of  conservatism  and  the  avoid- 
ance of  disfigurement  and  discomfort  through  loss  of  teeth  which  is 
thus  offered.    There  is  a  wide  difference  of  opinion  among  authorities 


284 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


as  to  the  frequency  with  which  neuralgia  may  be  central  or  peripheral. 
Most  writers,  however,  are  agreed  that  in  a  considerable  number  of 
cases  the  afl'ection  primarily  is  peripheral,  and  that  in  the  course  of 
time,  as  the  disease  continues  to  advance,  more  branches  and  deeper 
portions  of  the  nerve  become  involved,  until  finally  the  Gasserian 
ganglion  is  attacked.  In  addition  to  this  many  cases  are  on  record  of 
pathological  conditions  of  the  teeth,  mouth,  and  tooth  pulps  which 
could  without  doubt  have  caused  reflex  pain  of  serious  character  in 
patients  suffering  from  tic  douloureux  and  other  forms  of  neuralgic 


Fig.  145. — Section  of  the  pulp  of  a  tooth 
from  the  mouth  of  one  of  the  author's 
patients,  a  woman,  aged  forty-five  years, 
who  had  suffered  for  several  years  with  tic 
doviloureux.  The  tooth  from  which  this 
pulp  was  removed  was  on  the  affected  side 
and  at  the  point  where  the  earliest  pain 
appeared  to  begin:  a,  b,  pulp  nodules. 


Fig.  146. — Another  section  of  the  same 
pulp  shown  in  Fig.  145.  In  addition  to 
the  nodules  a,  b,  an  accompanying  pulp 
degeneration  is  particularly  evidenced 
at  c. 


pain.  Figs.  115,  116,  145,  14G  and  147  are  photomicrographs  of 
sections  of  tooth  pulps  removed  from  the  teeth  of  patients  suffering 
from  tic  douloureux.  They  were  isolated  and  their  conditions  diag- 
nosticated by  the  methods  given  below.  They  show  fibroid  and 
calcareous  degeneration  with  marked  alteration  of  form,  distribution, 
and  character  of  the  nerve  fibers  not  dissimilar  to  indications  (Plate  X) 
of  Gasserian  ganglia.  There  seems  every  reason  to  believe  that, 
either  as  a  primary  cause  or  as  a  result  of  the  paroxysmal  character 
of  exacerbations  of  pain  due  principally  to  other  and  remote  causes, 


DISEASES  OF  THE  DENTAL  PULP 


285 


the  continued  irritation  of  tooth  pulps  because  of  their  peculiar  his- 
tological character  and  environment  first  gives  rise  to  degenerative 
changes  in  these  organs  which  later  aft'ect  the  nerve  branches  in  more 
general  distribution.  Certainly,  search  in  this  direction  and  the 
treatment  of  even  suspected  tooth  pulps  should  precede  other  graver 
methods  of  treatment.  u      •  u 

Diagnosis.— General  examination  of  the  mouth  and  teeth  with  a 
view  of  determining  the  likelihood  of  peripheral  irritation  in  this  region 
should  include  examination  of  the  general  outline  of  the  dental  arch, 
face,  and  nose  to  note  the  possibility  of  ill  effect  from  imperfect  develop- 
ment as  described. 


Fig.  147. — Pulp  from  the  molar  tooth  of  a  man,  aged  forty  years.  Case  of  tic 
douloureux.  The  crown  of  this  tooth  showed  no  carious  or  other  serious  defect. 
a,  pulp  nodule. 

Earhj  Diagnosis.— ChMren  of  delicate  nervous  organization, 
especially  when  there  is  a  known  hereditary  tendency,  require  close 
observation  during  their  important  development  periods  to  detect 
any  tendency  to  arrest  of  growth  or  as^onmetrical  form  of  the  nose  or 
mouth  before  harmful  results  have  had  opportunity  to  give  serious 
manifestation.  At  later  periods  irregular  dental  arches,  high,  narrow 
palatal  vaults,  adenoids,  enlarged  tonsils,  mouth-breathing,  and  the 
symptoms  of  imperfect  oxygenation,  and  ill-nourishment  that  are 
associated  with  these  conditions  when  present  in  conjunction  with 
pain  in  the  region  of  the  fifth  nerve  render  the  diagnosis  of  causal 
factors  of  this  character  quite  simple. 

Diagnostic  hidications  after  the  Eruption  of  fee^/z.— Examination 
of  the  occlusal  surfaces  of  the  teeth  is  of  first  importance,  particularly 


286  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

in  cases  in  which  they  are  abraded  at  points  which  do  not  come  in  con- 
tact in  normal  occhision,  as  this  is  an  indication  of  the  jaw-biting  habit. 
Patients  are  almost  invariably  unconscious  of  the  habit,  but  usually 
after  tooth  surfaces  that  they  have  been  accustomed  to  bite  upon  are 
ground  until  they  no  longer  meet  in  occlusion,  such  patients,  when 
next  seen,  as  a  rule,  admit  having  noticed  the  loss  of  the  grinding  sur- 
faces and  are  therefore  convinced.  Elongation  or  looseness  of  teeth 
points  to  chronic  pericemental  thickening.  This  may  or  may  not  be 
noticeable  when  jaws  are  closed.  It  may  be  diagnosticated  by  placing 
a  finger  inside  the  cheek  or  lips,  allowing  its  palmar  surface  to  rest 
against  the  buccal  or  labial  surfaces  of  the  teeth  with  light  pressure. 
When  the  jaws  are  closed  a  slight  movement  of  the  afi'ected  tooth  can 
sometimes  be  felt,  even  though  not  noticeable  in  other  examinations. 
Study  of  the  color  of  the  mucous  membrane  of  the  lips  and  mouth  and 
the  appearance  of  the  gums,  salivary  and  other  glands  in  the  buccal 
region  indicates  the  general  state  of  the  patient,  and  shows  whether 
he  is  anemic  or  affected  by  auto-intoxication  or  any  other  general 
disturbance  which  might  be  an  etiological  factor.  The  presence  or 
absence  of  carious  or  diseased  teeth  should  be  noted,  with  particularly 
careful  search  for  a  carious  tooth  cavity  through  which  a  pulp  might 
have  become  exposed  to  undergoing  chronic  degeneration  of  any  kind. 
Metal  crowns  or  bridge-work  that  might  indicate  tooth  grinding  should 
also  be  noted.  The  occlusal  surfaces  of  the  molars  and  bicuspids  and 
incisal  portions  of  the  six  anterior  teeth  should  be  examined,  with 
careful  observation  of  the  worn  surfaces  of  the  enamel  or  bright  shining 
spots  in  fillings.  The  mandibular  articulation  must  receive  attention 
to  note  whether  there  be  undue  enlargement  or  other  abnormality 
in  the  region  of  the  temporomaxillary  articulation.  The  teeth  must  be 
carefully  counted  and  the  presence  or  absence  of  each  tooth  accounted 
for,  particularly  the  third  molars.  If  there  be  doubt  or  uncertainty 
in  this  respect,  a  radiograph  should  always  be  taken  to  determine 
whether  malposed,  unerupted,  or  supernumerary  teeth  exist.  The  necks 
of  the  teeth  should  be  examined  at  points  where  recession  of  the  gum 
may  have  exposed  sensitive  dentin  to  irritation.  This  has  been 
reported  as  a  cause  by  Inglis.  Difference  in  color  must  be  carefully 
observed  with  reflected  light  through  the  crown  of  the  teeth,  if  possible 
with  an  electric  mouth  lamp.  Discoloration  indicates  devitalized 
pulps  or  pulp  calcification,  teeth  of  this  character  being  somewhat 
darker  than  the  crowns  of  normal  living  teeth.  The  size  of  all  fillings 
must  be  compared  in  proportion  to  crowns  of  teeth  filled,  to  form  an 
idea  as  to  the  likelihood  of  the  filling  having  been  placed  too  close  to 
the  pulp  chamber.  Improperly  constructed  bridge-worh  with  imperfect 
occlusion  and  cases  in  which  teeth  or  roots  have  been  used  as  abut- 
ments and  suffer  too  great  strain  in  carrying  too  many  bridged  teeth 
should  be  noted;  also  cases  in  ^\■hich  there  is  an  abutment  at  only  one 
end  of  the  bridge,  one  tooth  being  allowed  to  support  crowns  to  supply 
one  or  more  missing  teeth.    Any  of  these  conditions  would  lead  at  once 


DISEASES  OF  THE   DENTAL  PULP  287 

to  suspicion  of  pericemental  diseases  which  might  be  expected  to  lead 
to  chronic  pulp  affections.  In  certain  forms  of  trigeminal  neuralgia 
the  pain  quite  frequently  is  greater  at  night  or  ivhen  the  patient  is  lying 
down.  While  this  is  sometimes  a  symptom  due  to  other  causes,  it  is  at 
least  a  reasonably  good  indication  that  the  causative  factor  lies  in  some 
form  of  pulpitis,  as  in  diseases  of  the  dental  pulp.  The  change  in  pos- 
ture favoring  increased  circulation  of  blood  in  the  upper  portion  of  the 
body  almost  invariably  gives  the  onset  or  increase  of  pain.  This  was 
very  marked  in  one  of  the  author's  patients.  The  history  of  this  case 
as  given  by  the  physician  who  referred  him  was  that  during  a  period 
of  a  number  of  weeks  the  man  had  suffered  from  excruciating  unilateral 
trigeminal  pain.  Morphin  had  been  administered  up  to  the  limit  of 
safety,  but  it  seemed  to  be  impossible  to  give  relief  when  the  patient 
was  lying  down.  When  he  stood  up  relief  was  so  prompt  that  he 
slept  without  difficulty  by  leaning  against  the  wall  in  an  erect  position. 
Diagnosis  of  the  cause  was  quickly  made,  and  an  upper  molar  tooth 
extracted  which  to  all  outward  appearances  was  perfectly  sound. 
Upon  breaking  the  tooth  open  the  pulp  chamber  was  found  to  be  filled 
with  pulp  nodules,  and  the  pain  disappeared  almost  immediately. 

Percussion  w'ith  a  steel  instrument  may  disclose  tenderness  to  tap- 
ping, or  there  may  be  no  abnormal  evidences  other  than  a  slight  dulness 
of  sound  W'hich  distinguishes  teeth  having  pathological  conditions  of 
the  pericementum.  Anhylosed  teeth  give  a  slightly  sharp  or  ringing 
sound  on  percussion,  because  the  deadening  effect  of  the  pericementum 
which  normally  acts  as  a  cushion  is  lost  by  its  obliteration. 

Bulging  or  Enlargement  of  the  Alveolar  Surface  Over  Boots. — Hyper- 
cementosis  that  has  progressed  to  a  sufficient  extent  by  encroachment 
upon  surrounding  alveolar  structures  sometimes  gives  the  appearance 
of  grow^th  at  certain  points  over  the  roots,  which,  taken  with  the  altered 
resonance  of  percussion,  assists  the  discovery  of  this  condition.  This 
form  of  diagnosis  has  many  times  led  to  the  location  of  teeth  which 
were  exciting  factors  in  painful  neuralgias.  In  one  of  the  author's  cases, 
a  woman  with  hyperesthesia  so  marked  that  she  admitted  not  having 
washed  her  face  for  more  than  three  months,  the  sensitiveness  was 
such  that  touching  the  lips  almost  anywhere  brought  forth  extreme 
paroxysms  of  pain,  and  under  these  conditions,  which  made  diagnosis 
extremely  difficult,  no  important  guiding  symptom  was  found  other 
than  dulness  on  percussion  of  an  upper  bicuspid  tooth.  Immediately 
following  the  extraction  of  this  tooth  the  hyperesthesia  disappeared 
and  upon  breaking  it  open  the  pulp  chamber  was  found  filled  with  a 
finely  granulated  powder  resulting  from  calcareous  degeneration  of 
the  pulp.  This  did  not  completely  relieve  the  patient,  but  the  dis- 
tressing hyperesthesia  was  at  once  relieved  and  other  painful  symptoms 
much  improved. 

Skiagraphs  carefully  taken  sometimes  assist  diagnosis  very  materi- 
ally, especially  when  hypercementosis  is  marked.  They  are  exceed- 
ingly useful  in  disclosing  diseased  conditions  of  the  roots  of  teeth 


288  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

sufficiently,  when  these  have  been  imperfectly  filled.  Many  inter- 
esting examples  of  the  value  of  skiagraphy  might  be  shown  in  which 
the  cause  of  long-continued  irritation  at  the  apical  portion  of  the  root 
of  the  tooth  has  proved  to  be  the  projection  of  a  root  filling  beyond 
the  apical  foramen  or  through  some  opening  in  the  side  of  the  root. 
Dento-alveolar  abscesses,  pericemental  abscesses,  and  diseased  condi- 
tions of  surrounding  alveolar  structures,  particularly  unusual  necrotic 
conditions,  have  been  disclosed  in  this  way.  In  the  various  forms 
of  pathological  dentition,  such  as  malposed,  unerupted,  or  super- 
numerary teeth,  especially  with  delayed  dentition,  dentigerous  cysts, 
and  odontomes,  the  a;-rays  are  useful  beyond  all  other  diagnostic  aids. 
Pus,  tumors,  and  foreign  bodies  in  the  maxillary  sinus  may  sometimes 
be  advantageously  determined  by  the  use  of  the  .r-rays. 

No  other  agent  is  equally  useful  in  ascertaining  the  exact  con- 
ditions of  recent  fractures  of  the  jaws  in  which  union  has  been  delayed 
or  faulty,  is  complicated  by  necrosis  and  malposition  of  the  bones, 
or  has  taken  place  without  correct  approximation  with  consequent 
permanent  deformity  or  pain  from  pressure  upon  nerves  and  palate 
vessels. 

Sensitiveness  to  Heat  and  Cold. — The  most  important  test  of  a  tooth 
pulp  as  indicating  healthfulness  on  the  one  hand,  or  impaired  vitality 
on  the  other,  is  its  reaction  to  heat,  cold,  and  other  forms  of  irritation. 
A  normal  pulp  should  react  quickly  to  irritation  with  sharp  pain  if 
sufficiently  disturbed,  but  with  the  vitality  and  its  vascular  supply 
unimpaired,  the  transient  hyperemia  induced  by  stimuli  of  this  char- 
acter should  be  promptly  relieved.  Therefore  the  pain  should  dis- 
appear quickly.  Lessened  sensitiveness  indicates  lowered  vitality. 
Slowness  of  disappearance  of  pain  indicates  loss  of  circulatory  activity 
probably  due  to  chronic  hj^peremia  and  the  impaired  ability  of  the 
coats  of  the  vessels  to  free  themselves,  indicating  the  partial  stasis  of 
inflammatory  processes  or  other  degenerative  changes. 

The  temperature  test  of  a  pulp  then  consists  in  the  suddenness  of 
the  onset  of  pain  upon  application  of  heat  or  cold  and  the  promptness 
with  which  the  pain  disappears.  The  same  is  true  of  other  irritations. 
When  pulpitis  is  present  the  pain  may  continue  for  a  few  minutes" 
or  a  few  hours,  or  reflex  disturbance  of  important  serious  character 
may  be  excited.  This  also  is  an  indication  that  degenerative  processes 
have  become  sufficiently  advanced  to  involve  more  distant  portions 
of  the  nerve  supply.  Applying  this  knowledge  to  the  diagnosis  of 
neuralgia,  we  recognize  that  the  onset  of  pain  when  breathing  cold  air 
through  the  mouth,  ^^■hen  riding  or  walking,  or  increase  of  pain  upon 
entering  a  warm  room  from  outer  cooler  air,  may  be  taken  as  indications 
of  peripheral  irritation  from  some  hypersensitiveness  or  diseased  tooth 
pulp.  The  onset  or  increase  of  pain  when  hot,  cold,  sweet,  or  sour 
substances  are  taken  into  the  mouth  may  be  taken  as  a  fairly  good 
indication  of  tooth  pulp  disturbance.  The  cessation  of  pain  when 
the  mouth  is  filled  with  iced  water  which  is  held  there  and  changed 


DISEASES  OF  THE  DENTAL  PULP  289 

with  sufficient  rapidity  to  insure  continued  cold  is  another  indication, 
because  at  a  certain  stage  of  pulpitis  the  application  of  ice,  iced  water, 
or  any  form  of  sufficiently  cold  application  will  stop  the  pain.  At  an 
earlier  or  later  stage  of  the  pulpitis,  even  in  the  same  tooth  pulp,  this 
might  excite  intensely  painful  s^^^lptoms,  but  at  just  the  right  moment 
the  contraction  of  the  ^"essels  by  cold  gives  prompt  relief.  In  testing 
individual  teeth  for  temperature  changes  care  must  be  exercised  to 
isolate  each  particular  tooth  in  order  that  one  may  accurately  de- 
termine exactly  which  tooth  is  the  exciting  cause.  Too  often  both 
heat  and  cold  are  applied  in  a  more  or  less  general  way,  and  although 
the  indications  may  lead  to  diagnosis  of  dental  trouble  the  particular 
teeth  in^•olved  are  not  so  readily  discovered.  A  simple  way  of  apply- 
ing heat  is  to  take  a  mass  of  dentist's  base-plate  gutta-percha  as  large 
as  the  first  joint  of  a  little  finger,  hold  with  an  instrument  in  the  flame 
of  a  spirit  lamp  to  soften  the  gutta-percha,  roll  into  a  mass,  and  point 
it  at  one  end  so  that  ^^■hen  applied  to  the  tooth  only  one  may  be  touched 
at  a  time.  ^Yhen  this  is  applied  as  hot  as  it  can  be  made  without 
burning  and  with  care  to  avoid  touching  the  gums,  the  response  of  each 
particular  tooth  in  the  mouth  to  heat  may  be  accurately  noted.  Teeth 
which  fail  to  respond  are  probably  devitalized,  and  care  should  be  taken 
to  know  that  each  tooth  of  this  kind  has  been  properly  treated  and 
its  roots  filled.  If  pulps  are  alive  the  response  of  all  teeth  will  be 
approximately  the  same.  Variations  from  this  should  be  noted. 
\Yhen  pain  appears  immediately  in  the  track  of  a  neuralgia  at  some 
more  or  less  distant  point  in  the  distribution  of  the  fifth  nerve  upon 
the  application  of  heat  in  this  wa}',  and  this  pain  continues  longer 
than  the  normal  time  required  for  the  tooth  to  regain  its  usual  tempera- 
ture, it  is  an  indication  that  the  pulp  of  such  a  tooth  or  teeth  must 
receive  treatment. 

The  simplest  way  to  apply  cold  is  to  take  a  piece  of  ice,  sharpened 
to  a  point  at  one  end,  of  such  shape  that  it  can  be  wrapped  in  a  napkin 
and  held  without  difficulty,  and  each  tooth  touched  one  after  the  other 
with  the  sharp-pointed  exposed  portion  of  the  ice.  The  indication  and 
inequality  and  situation  of  pain  excited,  and  the  time  required  for  its 
disappearance  are  the  determining  factors  as  with  heat.  Tests  of  this 
kind  are  particularly  useful  in  leading  to  the  discovery  of  pulp  nodules 
or  fillings  that  have  been  placed  too  close  to  the  pulp  chamber. 
Quite  frequently  pulp  stones  are  discovered  in  this  way  when  tooth 
pulps  having  such  s}'mptoms  have  been  removed  that  could  have 
been  discovered  in  no  other. 

Treatment. — With  children  or  young  persons  as  a  prophylactic 
measure  the  natural  remedy  is  expansion  of  dental  arches,  by  separa- 
tion of  the  maxillae  to  ^^■iden  the  nose.  This  gives  the  benefit  of  more 
perfect  physiological  respiration,  assists  the  natural  eruption  of  devel- 
oping teeth,  and  gains  the  general  developmental  benefit  of  improved 
respiration.  This  is  described  more  in  detail  in  illustrations,  pages 
555-558. 
19 


290  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

The  question  of  treatment  of  teeth  in  neuralgic  patients,  particu- 
larly those  suffering  from  major  neuralgia  or  tic  douloureux,  is  often 
a  serious  matter.  With  or  without  real  cause  patients  quite  often 
suffer  pain  in  a  particular  tooth,  and  they  are  always  desirous  of  its 
extraction.  But  it  should  be  remembered  that  almost  invariably  as 
much  can  be  done  to  give  relief  by  removal  of  the  pulp  and  the  proper 
treatment  of  the  root  canals,  thus  disposing  of  the  irritating  factor  as 
completely  as  if  the  tooth  had  been  extracted.  On  the  other  hand, 
every  time  a  tooth  is  extracted  the  occlusion  of  the  jaws  is  disarranged, 
as  has  been  already  noted.  Such  patients  during  the  paroxysms  of 
their  suffering  always  clinch  and  grind  their  teeth.  AVhile  temporary 
relief  can  be  given  by  the  extraction  of  a  particular  tooth  that  is  elon- 
gated, tender  to  touch,  or  that  has  a  diseased  pulp,  almost  invariably 
within  a  short  time  after  its  extraction  one  of  the  adjoining  teeth 
becomes  similarly  affected.  Being  deprived  of  the  natural  support 
which  each  tooth  gives  to  its  fellow  in  the  dental  arch,  it  more  readily 
succumbs  to  the  overuse  thus  brought  about,  and  pulpitis  from  irrita- 
tion of  the  pericementum  affecting  the  nerves  and  vessels  where  they 
enter  the  apical  foramen  is  quickly  conveyed  to  the  tooth  pulp  itself. 
Thus  it  is  a  common  experience  to  find  patients  who  have  had  all  of  the 
teeth  upon  the  affected  side  extracted  one  after  the  other,  or  when 
all  have  not  yet  been  removed  and  a  few  taken  out,  the  remaining 
teeth  are  found  leaning  at  a  very  considerable  angle,  having  been  forced 
out  of  position  by  the  unusual  stress  to  which  they  have  been  subjected. 
The  indiscriminate  extraction  of  teeth  in  this  way  seldom  ever  does 
permanent  good  and  almost  always  more  or  less  harm. 

Dentists  are  sometimes  reluctant  to  destroy  more  or  less  ruthlessly 
the  pulps  of  teeth  that  are  outwardly  perfect  in  appearance,  and  such 
opinion,  based  as  it  is  upon  true  conservatism,  is  entitled  to  respect. 
But  it  must  be  remembered  that  the  value  of  a  dental  pulp  or  even 
of  teeth  when  compared  with  the  suffering  and  other  physical  disad- 
vantages which  follow  in  the  train  of  neuralgia  of  grave  character 
should  not  be  allowed  to  weigh  in  the  balance  to  any  considerable 
extent.  It  is  an  exceedingly  simple  procedure  for  a  skilful  dentist  to 
open  a  suspected  tooth,  and  by  cocainizing  the  pulp  with  pressure 
anesthesia  to  remove  it  painlessly,  and  with  proper  treatment  to  fill 
the  root  canals,  thus  preserving  the  usefulness  of  the  tooth,  not  only 
for  its  original  masticatory  and  cosmetic  purposes  but  as  a  safeguard 
against  the  continued  progress  of  the  dental  irritation  through  the 
influence  of  the  affection  itself. 

Malocclusion  must  be  corrected  by  grinding  the  surfaces  of  teeth 
that  have  become  elongated  or  by  proper  dental  operations  to  prevent 
undue  stress  upon  the  affected  teeth.  Grinding  the  surfaces  of  the 
teeth  which  are  most  abraded  to  overcome  the  habit  and  various  other 
expedients  have  been  found  useful  to  prevent  tooth  grinding  at  night, 
such  as  tying  rubber,  cotton,  or  other  materials  over  the  surface  of  one 
or  more  back  teeth  to  keep  the  jaws  slightly  apart,  gum  held  between 


DISEASES  OF  THE  DENTAL   PULP  291 

the  jaws  at  night,  etc.  IMuch  relief  has  been  given  to  large  numbers  of 
patients  during  several  years  past  by  the  insertion  of  an  appliance 
called,  for  want  of  a  better  name,  the  author's  soft-rubber  bit  (Fig.  148). 
This  is  an  exceedingly  simple  but  very  useful  appliance,  made  as  shown 
with  a  hard-rubber  plate  fitting  the  palate  and  having  soft  velum 
rubber  extending  over  the  crown  surfaces  of  the  teeth  one-eighth  to 
one-quarter  of  an  inch  in  thickness.  The  soft  yielding  surface  of  the 
rubber,  A\hen  the  jaws  are  brought  in  contact,  prevents  undue  irrita- 
tion of  individual  teeth.  The  effect  of  the  appliance  in  the  mouth 
and  the  inability  to  bring  into  contact  the  tooth  surfaces  that  have 
been  held  tightly  together  or  have  been  ground  during  subconscious 
moments  and  sleep  in  time  helps  to  overcome  the  habit.  The  steadi- 
ness which  is  given  to  the  lower  jaw  when  forced  against  the  upper 
relieves  nerve  tension  in  such  individuals  very  materially.  In  most 
cases  certain  changes  in  the  way  of  enlargement  have  taken  place 


Fig.  148. — The  author's  rubber  appliance  to  relieve  stress  in  case  of  "jaw-clinching 
habit"  and  ner^-ous  tooth  grinding.  The  palatal  portion  is  made  of  hard  -^-ulcanized 
rubber,  and  the  covering  for  the  occlused  surfaces  of  the  teeth  is  of  soft  velum  rubber. 

in  the  region  of  the  temporomaxillary  articulation  which  allows  a  much 
greater  irregularity  of  movement  of  the  jaw  than  is  normally  the  case. 
The  continued  seeking  for  a  proper  resting  place  is  one  of  the  marked 
s^'mptoms,  and  has  invariably  proved  to  be  an  important  factor  in 
relation  to  nerve  strain  and  irritation.  Many  patients  could  be  cited 
who  have  been  completely  relieved  by  this  treatment. 

A  young  lady,  aged  twenty-three  years,  suffered  for  five  years 
almost  constant  pain,  chiefly  in  the  occipital  region,  but  at  times 
involving  also  other  regions.  Her  sleep  was  much  disturbed,  and  she 
usually  awoke  in  the  morning  with  the  pain  much  worse.  Her  s}Tnp- 
toms  finally  became  so  bad  that  she  lost  self-control  almost  entirely. 
Xo  other  treatment  was  given  except  the  constant  wearing  of  this 
appliance,  hygienic  care,  and  rubbing  with  alcohol  for  relief  during 
acutely  painful  periods.  In  a  little  while  she  became  absolutely 
dependent  upon  the  appliance,  and  in  the  coarse  of  time  the  trouble 
gradually  and  completely  disappeared. 


292  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Another  young  woman,  aged  forty  years,  a  chronic  sufferer  from 
neuralgia,  who,  although  five  feet  three  and  one-half  inches  in  height, 
weighed  only  ninety-seven  pounds  when  the  appliance  was  inserted, 
was  relieved  in  the  same  way. 

Temporomaxillary  Articulation. — Examination  of  skulls  in  the 
cadaver  and  dried  specimens  as  well  as  observation  and  study  of  the 
movement  of  the  condyles  show  great  variation  in  size  and  form  of  the 
glenoid  cavities  of  difl'erent  individuals  and  often  on  the  two  sides 
of  the  same  individual.  This  manifests  itself  as  a  factor  in  the  pro- 
duction of  certain  diseases  of  the  teeth  and  their  surrounding  structures. 
It  also  may  become  an  influential  factor  in  the  production  of  pain. 
There  are  many  cases  on  record  in  which  trigeminal  neuralgia  has 
been  relieved  by  the  insertion  of  suitable  plates  to  hold  edentulous 
jaws  sufficiently  apart  to  keep  the  condyloid  and  coronoid  processes 
of  the  lower  jaw  in  right  relation  to  the  surrounding  parts.  In  the 
same  way  persons  have  been  relieved  by  elongation  of  teeth  by  dental 
operations  when  the  crowns  have  become  so  abraded  as  to  allow  the 
jaws  to  come  too  close  together.  Cysts,  particularly  the  dentigerous 
cysts  of  erupting  teeth,  sometimes  cause  pressure  upon  important 
nerve  branches.  Engorgement  or  empyema  of  the  maxillary  sinus 
through  pressure  of  fluid  is  a  frequent  source  of  irritation  of  the  second 
division  of  the  nerve. 

BIBLIOGRAPHY. 

1.  Deutsch.  Ztschr.  f.  Chir.,  1899,  Band  xlii,  Heft  3  u  4. 

2.  Verhandl.  d.  Deutsch.  Gesell.  f.  Chir.,  1899. 

3.  St.  Louis  Med.  Rev.,  March  18  and  25.  1899. 

4.  Annals  of  Surgery,  1896,  xxiv,  575  to  619. 

5.  Head:     Trigeminal  Neuralgia,  Allbutt's  System,  1899,  vi,  728. 

6.  Horsley,  Victor:  An  Address  on  the  Surgical  Treatment  of  Trigeminal  Neuralgia, 
Practitioner,  1900,  Ixv,  251. 

7.  Rose:     Lancet,  1892,  i,  295. 

8.  Coehlo:     Rev.  de  Chir.,  1899. 

9.  Lexer,  E.:     Arch.  f.  klin.  Chir.,  1902,  Ixv,  843. 

10.  Jour.  Am.  Med.  Assn.,  April  29,  1900,  p.  1035. 

11.  Frazier:     Univ.  Penna.  Med.  Bull.,  December,  1901. 

12.  Spiller:     Am.  Jour.  Med.  Sc,  1898,  p.  532. 

13.  Barker:  Protocols  of  Microscopic  Examination  of  Several  Gasseriau  Ganglia, 
Jour.  Am.  Med.  Assn.,  May  5,  1900,  p.  1093. 

14.  Spiller  and  Frazier:  Division  of  the  Sensory  Root  of  the  Trigeminus  for  the 
Relief  of  Tic  Douloureux,  etc.,  Univ.  Penna.  Med.  Bull.,  xiv,  34. 

15.  Baer,  Dawson,  Marshall:  Regeneration  of  the  Dorsal  Root  Fibers  of  the  Second 
Cervical  Nerve  within  the  Spinal  Cord,  Jour.  Exper.  Med.,  1899,  iii,  No.  1. 

16.  Jour.  Am.  Med.  Assn.,  April  28,  1900. 

17.  Centralbl.  f.  Chir.,  1900,  No.  44,  p.  1089. 

18.  Bartlett:  Contribution  to  the  Surgical  Anatomy  of  the  Middle  Cranial  Fossa, 
Annals  of  Surgery,  1902. 

19.  Bartlett:     Excision  of  the  Intact  Gasserian  Ganglion,  Annals  of  Surgery,  1901. 

20.  Lexer:     Arch.  f.  klin.  Chir.,  1902,  Ixv,  14. 

21.  Dorrance:     Dental  Cosmos,   January,    1917. 

LESIONS  OF  THE  FACIAL  (SEVENTH)  NERVE. 

Anatomical  Relations. — The  commonly  accepted  belief  that  the 
seventh  or  facial  nerve  is  entirely  a  motor  nerve  is  questioned  by  more 


LESIONS  OF  THE  FACIAL  NERVE  293 

recent  investigators.  Its  main  distribution,  however,  is  to  the  muscles 
of  expression.  Its  point  of  origin  is  the  inferior  portion  of  the  general 
motor  areas  ventral  of  the  fissure  of  Rolando,  The  axons  pass  into  the 
pons  accompanying  the  general  motor  tract. 

The  peripheral  nerve  in  its  passage  from  the  nucleus  forms  a  loop 
about  the  nucleus  of  the  sixth  nerve,  thence  passes  ventrally  to  emerge 
in  close  relation  with  the  auditory  nerve,  separated  by  it  from  the  pars 
intermedia  (nerve  of  Wrisberg).  These  nerves  together  pass  into  the 
internal  auditory  meatus.  Centrally  it  is  connected  with  the  upper 
part  of  the  glossopharyngeal  nucleus,  and  may  improperly  be  regarded 
as  forming  the  sensory  portions  of  the  seventh  nerve  and  the  main  part 
of  the  chorda  tympani.  The  seventh  nerve,  peripheral  to  the  genic- 
ulate ganglion,  passes  into  the  Fallopian  canal,  runs  between  the 
cochlea  and  vestibule  into  the  inner  wall  of  the  tympanum,  separated 
from  the  tympanum  by  a  thin  lamella  of  bone  and  lining  membrane 
of  the  middle  ear,  finally  emerging  from  the  skull  through  the  stylo- 
mastoid foramen.  The  geniculate  ganglion  lying  at  the  bend  of  the 
nerve  corresponds  to  a  ganglion  of  a  dorsal  root.  In  addition  to  the 
supply  of  the  facial  muscles  of  expression,  the  facial  nerve  sends  fibers 
to  the  platysma,  posterior  belly  of  the  digastric,  the  stylohyoid,  and 
a  small  twig  within  the  Fallopian  canal  to  the  stapedius  muscle  of 
the  ear. 

Facial  Paralysis. — Paralysis  of  the  seventh  nerve  is  more  frequent 
than  that  of  any  other  nerve  in  the  body.  In  a  large  majority  of  cases 
the  affection  is  unilateral  and  caused  by  a  lesion  in  peripheral  distri- 
bution of  the  nerve. 

Etiology, — Its  known  and  suspected  causes  are  many,  and  given  in 
the  order  of  their  importance  are  approximately  as  follows : 

Exposure. — It  has  been  estimated  that  70  per  cent,  of  all  cases  show 
this  etiological  factor,  and  though  the  reason  does  not  seem  to  be  clear, 
facial  paralysis  occurring  after  exposure  to  draughts  or  similar  con- 
ditions so  overshadows  other  factors  in  frequency  as  to  warrant  its 
enumeration  as  an  exciting  cause. 

Suppurative  Ear  Disease. — Suppurative  ear  disease  is  extremely 
common  because  of  the  close  proximity  of  the  Fallopian  canal  through 
which  the  nerve  passes  to  the  frequently  diseased  auditory  region. 

Trauma. — Injury  of  direct  character  to  the  nerve  itself  or  sur- 
rounding structures  is  a  common  cause,  especially  surgical  or  other 
division  of  the  nerve. 

Basal  Fractures. — Thomas  states  that  in  69  cases  of  nerve  involve- 
ment from  skull  fracture,  34  showed  an  affection  of  the  facial  nerve. 

Disease  of  the  Base  of  the  Brain. — Meningitis,  new  tumor  growths, 
and  affections  of  the  medulla  and  pons,  readily  lead  to  involvement 
of  one  or  both  facial  nerves. 

Neuropathic  Teiidefwy.— 'While  predisposition  of  this  character 
plays  a  part  in  this  as  with  other  nerve  affections,  it  does  not  seem  to 
warrant  important  consideration  as  a  direct  factor,  although  instances 


294  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

of  the  occurrence  of  facial  paralysis  affecting  more  than  one  member 
of  the  same  family  prevents  complete  exclusion  of  this  contributing 
factor. 

Constitutional  Disease. — Gout,  diabetes,  leukemia,  syphilis,  tuber- 
culosis, and  similar  conditions  may  be  factors  of  primary  or  secondary 
importance,  as  may  also  the  puerperal  state  and  diphtheria. 

Emotional  Shock.- — Emotional  shock  has  in  a  number  of  instances 
been  followed  by  facial  paralysis. 

Neuritis. — Neuritis  or  a  primary  degeneration  of  the  nerve  within 
the  aqueductus  fallopii  have,  in  a  limited  number  of  cases  reported  by 
Andre  Thomas,  been  demonstrated  to  be  active  factors  in  this  affec- 
tion. 

Polyneuritis. — Polyneuritis  may  occur  in  conjunction  with  this 
condition,  and  in  these  cases  the  paralysis  is  usually  double-sided. 

Poliomyelitis. — Atrophy  and  paresis  of  the  tongue  and  pharynx 
sometimes  follow  the  symptoms  of  general  emaciation  and  muscular 
fibrillation,  which  are  indicative  of  degenerative  conditions  of  the  spinal 
cord. 

Periods  of  Life. — Periods  of  life  bear  their  usual  importance  in  this 
relation.  Paralysis  of  the  facial  nerve  is  more  frequent  before  forty 
and  more  severe  though  less  frequent  in  later  life. 

Symptoms. — The  onset  of  the  facial  paralysis  is  usually  rapid.  Pain 
located  in  the  ear,  the  mastoid  region,  or  neck  sometimes  occurs  as  a 
premonitory  symptom,  but  with  too  little  certainty  to  warrant  diag- 
nostic or  prognostic  dependence.  There  may  be  fever  and  other  signs 
of  infection  at  the  onset.  The  most  prominent  symptom  is  complete 
or  partial  loss  of  movement  of  the  muscles  upon  the  affected  side  of  the 
face.  Paralysis  of  the  orbicularis  oculi  prevents  closing  of  the  eyelid. 
Attempts  to  close  the  eye  result  in  the  globe  being  rolled  upward. 
In  smiling,  the  mouth  is  drawn  toward  the  unaffected  side.  The  lips 
cannot  be  properly  adjusted  in  attempts  to  whistle.  Drinking  and 
speech  are  interfered  with  (Figs.  149  and  150). 

Spasmodic  Contraction. — Spontaneous  twitching  of  the  face  muscles, 
particularly  the  zygomatic  muscles,  may  be  a  secondary  symptom, 
and  continue  for  years  or  be  totally  beyond  hope  or  recovery.  Without 
conclusive  evidence  it  is  generally  assumed  that  this  occurs  through 
degenerative  progress,  which  involves  the  pons  and  causes  loss  of 
control  of  nerve  impulse,  which  therefore  proceeds  irregularly  and  in 
excessive  degree.  (Facial  spasm,  tic,  etc.,  see  Spasmodic  Neuroses, 
page  303.) 

Location  of  the  lesion  is  sometimes  possible  through  consideration 
of  the  following  symptomatic  distinctions: 

1.  Between  the  exit  of  the  nerve  from  the  stylomastoid  foramen, 
taste  is  not  affected  because  the  chorda  tympani  joins  the  nerve  above 
these  points. 

2.  Between  the  stylomastoid  foramen  and  the  geniculate  ganglion 
within  the  Fallopian  canal.     Taste  in  the  two-thirds  of  the  anterior 


LESIONS  OF  THE  FACIAL  NERVE 


295 


part  of  the  tongue  so  affected  through  constant  involvement  of  the 
chorda  tynipani. 

3.  Between  the  geniculate  ganglion  and  pons.  There  is  no  involve- 
ment of  taste,  deafness  is  often  associated  through  involvement  of  the 
auditory  nerve. 

4.  In  the  pons,  taste  and  hearing  are  unaffected,  and  almost  invari- 
ably the  six  princii)al  other  nerves  are  all  affected.  In  the  central 
course  of  the  facial  nerve  no  changes  in  the  electrical  reaction  occur, 
the  upper  branch  of  the  nerve  is  much  less  involved  than  the  two  lower. 


Fig.  149.  —  Facial    paralysis    of    the    side. 
Attempt  to  raise  the  eyebrows.  (Starr.) 


Fig.  150. — Facial  paralysis  of  the  side. 
Attempt  to  close  the  eyes.  (Starr.) 


Diagnosis. — In  a  general  way  diagnosis  is  obviously  simple,  but  it 
is  especially  important  to  differentiate  between  a  central  disturbance 
in  the  nerve  and  one  due  to  a  peripheral  cause.  The  distinguishing 
features  in  making  this  differential  diagnosis  are  as  follows : 


CENTRAL. 

1.  No  change  in  electrical  reaction. 

2.  Upper  branches  of  the  peripheral 
nerve  are  sUghtly  involved. 

3.  Reflex  conditions  of  the  nerve  in- 
creased but  electrically  unchanged. 

4.  A  crossed  or  alternating  hemiplegia 
indicates  a  lesion  in  the  pons  below  the 
crossing  of  the  pyramid. 


PERIPHERY. 

1.  Electrical  reaction  always  present. 

2.  All  branches  of  the  nerve  equally 
involved. 

3.  Reflex    activities    diminished    with 
tendency  to  ultimate  atrophy. 

4.  No  such  condition  possible. 


Traumatic  injury  to  a  special  branch  of  the  nerve  may  in  a  measure 
modify  all  radical  lines  of  distinction. 

Prognosis. — The  duration  as  well  as  the  final  outcome  in  these  cases 
varies  from  one  or  more  weeks  to  months  or  may  be  permanent. 
There  may  be  recovery  even  with  complete  reaction  of  degeneration. 
When  this  condition,  however,  persists  for  months  and  a  quantitative 
diminution  of  electrical  excitability  results,  the  prognosis  is  grave 


296 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


because  of  permanent  changes  in  the  nerve  or  destruction  of  the  pontine 
nucleus.  In  a  general  way  it  may  be  assumed  that  with  electrical 
reactions  normal  or  nearly  so  and  the  period  short,  prognosis  would  be 
favorable,  and  with  loss  of  electrical  reaction  and  increased  length  of 
time  hope  for  recovery  be  correspondingly  diminished. 

The  following  clinical  example  illustrates  the  difference  between 
central  and  peripheral  causes  in  the  author's  cases: 

A  young  man,  aged  twenty-four  years,  unmarried,  with  facial 
symptoms  as  indicated  in  Figs.  151  and  152,  gave  a  history  of  paralysis 
having  continued  through  a  period  of  several  weeks.  He  had  also 
extensive  necrosis  of  the  lower  jaw  involving  several  teeth  which  was 
treated  by  the  removal  of  the  diseased  tissue,  but  no  portion  of  the 
facial  nerve  was  found  to  be  directly  involved.  His  death,  some  time 
after  leaving  the  hospital,  revealed  the  fact  that  his  affection  was  of 
central  origin.  There  was  no  opportunity  for  definite  location  of  the 
nature  of  the  lesion  by  autopsy. 


Fig.   151. — Facial  paralysis. 


Fig.  152. — Facial  paralysis.     The  effect 
of  an  attempt  to  close  the  eyes. 


Another  of  the  author's  patients,  a  young  woman,  aged  about 
twenty-six  years,  married,  had  symptoms  affecting  the  right  side 
of  her  face  quite  similar  to  those  of  the  young  man  just  described. 
Paralysis  occurred  a  few  days  before  presentation  for  treatment. 
There  was  suspicion  of  syphilis  in  this  case,  but  no  definite  diagnosis. 
The  removal  of  a  diseased  third  molar  upon  the  affected  side  caused 
marked  improvement  an  hour  or  so  later.  When  she  returned  home 
her  husband  was  surprised  and  astonished  at  the  change.  Following 
this,  the  sjonptoms  improved  slowly,  and  in  the  course  of  a  few  weeks 
completely  disappeared.  Whether  the  irritation  from  the  pulp  of  the 
third  molar  was  merely  a  contributing  factor,  and  the  removal  of  the 
tooth  through  the  stimulating  effect  of  the  shock  of  pain  aroused  was 


LESIONS  OF  THE  FACIAL  NERVE  297 

responsible  for  the  improvement,  or  if  by  some  anomaly  there  was  in 
this  individual  an  unusually  close  interweaving  of  sensory  and  motor 
elements,  or  if  such  relation  is  really  more  common  than  generally 
sup])osed,  is  of  course  impossible  to  say.  There  can  be  no  doubt, 
however,  of  the  fact  that  irritation  in  the  maxillary  region,  especially 
when  the  living  pulps  of  the  teeth  are  involved,  has  an  active  influence 
in  such  cases  of  secondary  if  not  primary  character.  For  an  old  lady, 
aged  sixty  years,  with  muscular  spasm  which  affected  the  right  side 
of  the  face  and  involved  the  superior  and  inferior  branches  of  the 
fifth  nerve,  the  removal  of  diseased  pulps  and  correction  of  maloc- 
clusion, which  was  aggravated  by  long-continued  tooth-grinding  habit, 
as  commonly  noted  in  many  nervous  states,  seemed  to  give  a  measure 
of  benefit  even  though  complete  relief  from  the  muscular  twitching 
was  not  accomplished,  and  the  affection  was  undoubtedly  due  to  a 
central  cause. 

Treatment. — ^The  treatment  is  radical  or  otherwise.  Effort  should 
be  made  to  correct  any  associated  pathological  condition  which  might 
possibly  be  an  exciting  or  contributing  factor.  Nature  must  be  assisted 
in  every  possible  way  to  further  natural  corrective  processes.  Medical 
treatment  should  therefore  be  to  keep  the  bowels  freely  active,  and 
include  the  administration  of  salicylates  when  indicated,  treatment  of 
s^'philis,  if  this  disease  be  recognized  as  an  etiological  factor,  by  the  use 
of  iodides  and  mercury,  and  the  relief  of  any  etiological  factor  that  may 
be  benefited  by  external  medication.  If  there  be  symptoms  of  neuritis 
within  the  Fallopian  canal,  hot  fomentations  may  be  applied  in  the 
mastoid  region,  or  direct  treatment  of  the  affected  parts  is  still  better. 
Electricity  is  probably  more  extensively  employed  than  any  other 
agent,  and  though  there  seems  to  be  some  doubt  as  to  its  permanent 
benefit,  it  appears  to  be  the  most  rational  means  of  stimulating  nerve 
and  muscle  activity  and  protecting  against  degenerative  progression. 

Dr.  E.  Farquhar  Buzzard  gives  the  following  outline  of  electrical 
treatment :  ''  In  treatment  by  these  means,  presuming  that  a  reaction 
of  degeneration  is  present,  the  galvanic  current  should  be  employed, 
using  over  the  affected  muscles  the  pole  which  produces  the  most 
marked  contraction.  No  more  than  four  or  five  milliamperes  should 
be  used,  and  the  muscles  should  be  stroked  by  an  electrode  for  a  period 
not  exceeding  ten  minutes.  As  the  faradic  irritability  returns,  this 
form  of  electricity  may  be  substituted  for  the  constant  current,  but 
it  is  well  to  discontinue  any  form  of  electric  treatment  when  the  ten- 
dency to  contracture  and  spasm  of  the  muscle  becomes  apparent. 
There  is  no  adequate  evidence  to  show  that  the  application  of  electric- 
ity plays  no  part  in  the  production  of  secondary  contracture,  but 
the  treatment  becomes  more  and  more  superfluous  as  voluntary  con- 
trol over  the  muscles  increases,  and  may  well  be  discontinued  before 
such  voluntary  control  becomes  complete." 

Surgical  Treatment. — Anastomosis  of  the  facial  with  the  spinal 
accessory  was  accomplished  by  Ballance  in   1895.     The  objection 


298 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


proved  to  be  tendency  to  paralysis  of  the  trapezius  and  sternomastoid 
muscles  and  involuntary  movement  of  the  shoulder.  Through  similar 
efforts  by  Gushing,  Faure,  Hackenbruch,  Kennedy,  and  others,  the 
hypoglossal  nerve  was  substituted  for  the  spinal  accessory,  and  by  only 
partial  division  of  the  h^-poglossal  difficulties  of  deglutition  and  speech, 
which  followed  complete  division  of  this  nerve,  were  avoided. 

Surgical  intervention  of  this  character  could  only  be  expected  to  be 
efficient  in  cases  of  traumatic  injury  or  division  of  the  facial  nerve, 
destructive  middle-ear  disease,  and  conditions  of  similar  character. 
To  be  effective,  the  operation  should  be  done  at  the  earliest  possible 
day  after  it  has  been  determined  that  constructive  processes  cannot  be 
looked  to  for  improvement  because  of  the  danger  of  muscle  disin- 
tegration through  inactivity. 


Fig.  153. — Nerve  anastomosis:  A,  intact  nerve;  B,  paralyzed  nerve;  I,  lateral  anasto- 
mosis (peripheral  implantation);  II,  lateral  anastomosis  (central  implantation).  (After 
Brewer.) 

Improvements  in  the  surgical  technic  and  better  understanding 
of  the  possibilities  of  nerve  anastomosis  are  encouraging  efforts  in  this 
direction  (Figs.  153  and  154).  Good  results  have  been  obtained  by 
Keen,  Ochsner,  and  other  surgeons  in  directly  suturing  the  ends  of 
divided  nerves  and  bridging  across  with  gut  sutures  between  them, 
when  the  nerve  ends  could  not  be  brought  into  direct  contact.  The 
wonderful  regenerative  power  of  nerve  structures  which  enables  them 
to  cross  bridges  of  this  character  and  become  perfectly  united  with 


LESIONS  OF  THE  AUDITORY  NERVE 


299 


restoration  of  function  has  thus  been  demonstrated.  These  facts  lead 
to  the  belief  that  in  the  future  divided  ends  of  the  facial  nerve  may  thus 
be  united  without  resorting  to  anastomosis  of  the  hypoglossal.  Cer- 
tainly, wherever  the  point  of  injury  or  di\'ision  of  the  nerve  is  so  situ- 
ated as  to  make  direct  union  possible,  this  method  would  be  favorable. 


Fig.  154. — Illustrating  method  of  fascio-accessory  anastomosis.     (Harvey  Gushing, 

after  Brewer.) 


LESIONS  OF  THE  AUDITORY  (EIGHTH)  NERVE. 

The  two  distinct  divisions  of  the  auditory  nerve,  first  the  cochlear 
portion,  in  which  the  organ  of  Corti  with  its  delicate  mechanism 
for  the  special  sense  of  hearing  is  situated,  and  the  vestibular  portion, 
which  bears  such  an  important  relation  in  the  phenomena  of  equilib- 


300  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

rium,  are  both  closely  related  in  various  ways  to  disease  in  the  oral 
region. 

Deafness  is  most  commonly  due  to  diseases  within  the  ear  affecting 
the  peripheral  fibers  of  the  nerve;  occasionally,  however,  hearing  is 
disturbed  by  affection  of  the  acoustic  nerve.  In  these  cases  there  is 
loss  of  power  of  perceiving  sound  through  the  bones  of  the  head,  and 
it  is  thus  distinguished  from  deafness  in  the  outer  or  middle  ear,  in 
which  the  sound  of  a  tuning-fork  can  be  heard  when  applied  to  the 
teeth,  forehead,  etc. 

Tiimitus  Aurium. — Ringing,  ticking,  hissing,  roaring,  or  whistling 
sounds  in  the  ear  occasion  the  individuals  so  affected  much  distress. 

Although  the  auditory  apparatus  accustoms  itself  to  the  almost 
constant  sounds  of  daily  life,  so  that  they  make  little  or  no  conscious 
impression,  subjective  sounds  due  to  morbid  processes  cause  an  increase 
rather  than  a  decrease  in  distressing  effect  upon  the  individual. 

Etiology. — Pathological  Conditions  of  the  Ear, — These  are  located 
especially  in  the  labyrinth,  but  include  also  wax  in  the  external  audi- 
tory meatus  and  affections  of  the  middle  ear.  Quinine,  the  salicylates, 
and  other  drugs  may  give  rise  to  tinnitus. 

Circulatory  Disorders. — Circulatory  disorders,  such  as  anemia, 
abnormal  pulsation  of  the  carotid  artery,  intracranial  aneurysm, 
vasomotor  palsy  of  the  labyrinthian  vessels,  arterial  sclerosis,  high 
or  low-pressure,  may  cause  tinnitus. 

Nervous  States. — Tinnitus  is  not  commonly  associated  with  hysteria, 
neurasthenia,  epilepsy,  and  migraine,  or  the  higher  centers  of  the 
cerebral  cortex  may  be  so  affected  as  to  give  rise  to  more  complicated 
auditory  hallucinations. 

Muscular  Movements. — Movement  of  the  palatal  muscles  or  drum- 
head, which  may  be  voluntary  or  involuntary,  accompanied  by  spas- 
modic contraction  of  the  muscles  of  the  face  or  otherwise,  gives  rise 
to  a  clicking  sound  produced  by  sudden  separation  of  the  moist  agglu- 
tinated walls  of  the  Eustachian  tube. 

Diagnosis. — The  oral  surgeon's  special  interest  in  this  affection  lies  in 
the  possible  relation  bet\\een  diseased  conditions  of  the  mouth  and  max- 
illary sinus  to  middle-ear  disease;  in  local  irritation  from  tooth  grind- 
ing, diseased  pulps,  or  similar  factors,  which  tend  to  aggravate  general 
nervous  conditions;  the  influence  of  buccal  pathological  states  upon  the 
blood  and  general  disorders,  which  are  recognized  as  factors  of  etio- 
logical importance,  and  in  results  of  operations  for  correction  of  cleft- 
palate  involving  the  palatal  muscles  and  their  part  in  control  of  the 
Eustachian  opening.  In  the  author's  practice  a  considerable  number 
of  cases  have  had  chronic  empyema  of  the  maxillary  sinus,  coincident 
with  tinnitus,  \\hich  was  undoubtedly  due  to  middle-ear  disease.  The 
general  involvement  of  mouth,  nose,  maxillary  sinus,  Eustachian  and 
mastoid  regions,  usually  make  it  difficult  to  determine  the  exact  pri- 
mary cause.  In  some  cases,  however,  direct  connection  with  dento- 
alveolar  abscesses  and  the  history  of  onset  of  the  symptoms  following 


GLOSSOPHARYNGEAL  AND  PNEUMOGASTRIC  NERVES     301 

development  of  the  abscess  upon  the  root  of  a  tooth,  left  little  doubt 
as  to  the  rightful  precedence  of  this  cause.  Certainly  no  treatment 
could  be  expected  to  be  permanently  effective  so  long  as  reinfection  of 
the  ear  from  the  sinus  or  the  mouth  was  possible.  Therefore  the  diag- 
nosis of  these  conditions  and  their  proper  treatment  is  exceedingly 
important.  Recognition  and  correction  of  other  mouth  affections  are 
also  in  varying  degree  important  for  the  same  reason. 

Differential  Diagnosis.  —  Differential  diagnosis  in  these  cases  is 
sometimes  extremely  difficult,  and  only  examination  by  an  otologist 
can  be  effective  in  distinguishing  between  the  different  forms  of  this 
affection  when  due  to  diseased  conditions  of  the  ear.  To  recognize 
pathological  states  which  might  be  of  etiological  importance  and  apply 
the  test  of  their  correction  when  possible  appears  to  be  the  only  safe 
rule  for  diagnostic  guidance  when  the  true  cause  is  not  apparent. 
Deafness  does  not  seem  to  bear  a  definite  relation  to  this  trouble, 
since  it  may  decrease  with  increasing  deafness  or  remain  unchanged. 

Prognosis. — The  prognosis  is  usually  not  hopeful.  In  large  numbers 
of  cases  the  affection  tends  to  persist  in  spite  of  every  treatment. 

Treatment. — Although  treatment  is  usually  ineffective,  the  utmost 
effort  should  be  made  to  remove  or  correct  any  predisposing  or  exciting 
cause  that  may  be  indicated.  Diseases  of  the  ear,  maxillary  sinus, 
nose,  throat,  or  mouth  should  be  given  immediate  attention.  The 
psychic  element  always  requires  intelligent  consideration  with  patients 
so  aflBicted,  for  cheerful,  helpful,  hopeful  suggestions  are  at  least 
encouraging  and  often  beneficial.  Conditions  of  the  blood  and  general 
disorders  of  that  character  must  be  corrected  if  possible.  Change 
of  air,  scene,  and  occupation,  and  the  administration  of  nervines,  tonics, 
or  other  internal  medication  may  be  required. 

LESIONS    OF   THE   GLOSSOPHAHYNGEAL    (NINTH)    AND   PNEU- 
MOGASTRIC (TENTH)  NERVES. 

The  ninth  nerve  contains  both  sensory  and  motor  fibers,  and  is  the 
nerve  of  common  sensibility  of  the  pharynx,  palate,  and  middle  ear. 
It  is  believed  that  it  supplies  sensation  of  taste  to  the  posterior  third 
of  the  tongue,  the  anterior  two-thirds  passing  in  through  the  lingual 
nerve.  Confusion  on  this  point  has  occurred  by  reason  of  the  fact 
that  division  of  the  root  of  the  trigeminal  nerve  has  sometimes  caused 
total  loss  of  taste,  and  there  is  reason  to  believe  that  individuals  differ 
some^^■hat  in  this  respect. 

The  association  of  this  nerve  in  both  its  motor  and  sensory  fibers 
with  the  vagus  or  tenth  nerve  (pneumogastric)  is  so  intimate  that 
clinically  a  radical  division  is  practically  impossible.  Injury  of  the 
motor  branches  causes  anesthesia  of  the  pharynx  and  larynx,  with 
difficulty  in  swallowing.  In  bulbar  paralysis  there  is  loss  of  action 
of  the  esophagus,  pharynx,  and  larynx.  The  wide  distribution  of  the 
tenth  nerve,  however,  with  its  control  of  respiratory  and  cardiac 


302  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

centers,  and  its  well-known  susceptibility  to  sympathetic  effect,  renders 
the  association  of  diseases  of  these  nerves  with  pathological  conditions 
of  the  mouth  matters  of  much  general  importance. 


LESIONS  OF  THE  SPINAL  ACCESSORY  (ELEVENTH)  NERVE. 

Paralysis. — Etiology. — ^Among  the  usual  causes  of  paralysis  of  the 
accessory  nerve,  we  find  swollen  glands,  abscess  of  the  neck,  and  similar 
affections.  The  frequency  with  which  these  conditions  occur  from 
buccal  infection  requires  at  least  a  passing  consideration. 

Symptoms. — Paralysis  of  the  sternocleidomastoid  and  trapezius 
muscle  through  loss  of  compensatory  action  causes  the  head  to  be 
turned  backward  and  over  the  shoulder,  which  is  also  elevated.  There 
is  loss  of  power  to  raise  the  arm  above  the  horizontal  line  through 
failure  of  the  trapezius  to  counteract  the  serratus  muscle,  which  retains 
the  scapula  in  such  manner  as  to  produce  a  slight  elevation  upon  the 
one  side  of  the  neck  by  the  projection  upward  of  its  inner  angle.  Tor- 
ticollis, or  wry-neck,  may  be  due  to  congenital  lesions  of  the  eleventh 
nerve,  defects  of  deformity,  or  injury. 

Diagnosis  and  Treatment.^ — Treatment,  except  when  other  causes 
are  obvious,  should  include  thorough  examination  for  sources  of 
infection  in  mouth  or  its  associated  glands  and  immediate  correction 
of  such  existing  conditions  if  any.  Beyond  this  its  consideration 
passes  outside  of  the  oral  surgical  and  therapeutic  domain. 


LESIONS  OF  THE  HYPOGLOSSAL  (TWELFTH)  NERVE. 

Paralysis. — The  hypoglossal  nerve  being  purely  motor  and  supplying 
all  of  the  tongue  muscles  except  the  glossopalatini  and  geniohyoid, 
paralysis  of  this  nerve  is  evidenced  by  motor  and  trophic  changes 
in  the  tongue. 

Etiology. — As  with  facial  or  other  paralysis,  its  primary  cause  may 
be  central  or  peripheral,  although  rarely  involved  in  lesions  upon  the 
base  of  the  brain.  It  is  a  quite  prominent  feature  in  bulbar  paralysis. 
Traumatic  injury,  tuberculosis,  syphilis,  and  other  diseases  identical 
with  those  enumerated  as  leading  to  other  forms  of  paralysis  may  be 
causes  (Fig.  155). 

Symptoms. — Prominent  symptoms  are  inability  to  move  the  muscles 
of  the  tongue  or  to  protrude  it  from  the  mouth.  One  or  both  hypo- 
glossal nerves  may  be  affected.  If  both,  there  will  be  general  loss 
of  lingual  motion.  If  one  nerve  only  be  involved,  when  the  tongue  is 
moved  its  tip  will  project  toward  the  paralyzed  side.  This  becomes 
more  and  more  apparent  as  the  tongue  is  extended  out  of  the  mouth. 
Mastication  and  deglutition  are  interfered  with.  Atrophy  is  a  marked 
symptom  if  the  lesion  be  peripheral  and  folds  or  ridges  upon  the  other- 
wise smooth  surface  give  indications  of  its  progress  (Fig.  156) . 


SPASMODIC  NEUROSES 


303 


Prognosis.^ — Its  termination  naturally  depends  upon  the  seat  of 
orifijin  and  the  nature  of  the  causative  factor. 

Treatment. — As  with  other  forms  of  paralysis,  treatment  must  be 
directed  toward  relief  of  the  underlying  condition. 


Fig.  155. — Gunshot  section  of  left  hypo- 
glossal nerve.     (After  Roberts.) 


Fig. 


156. — Right  hemiatrophy  of  the 
tongue. 


SPASMODIC  NEUROSES. 

Convulsions. — Clonic  spasm  is  an  alternate  muscular  contraction 
and  relaxation  that  is  violent  and  involuntar}'.  Tonic  spasm  is  a  rigid 
contraction  of  muscles  without  relaxation.  When  slight  it  is  called 
tremor;  when  strong  and  permanent,  tetanus,  trismus,  etc. 

Etiology. — In  most  cases  fits  occur  before  the  completion  of  the  first 
dentition.  Of  300  cases  studied  by  Cautley,  44  were  in  the  first  six 
months  of  life,  52  in  the  second,  76  in  the  second  year,  and  44  in  the 
third  year.  Of  these,  no  less  than  216  were  infants,  under  three  years 
of  age,  27  were  in  the  fourth  year,  and  the  remainder  under  twelve. 

McCarthy^  calls  attention  to  the  following  pathological  influences: 
Irritation  of  the  skin  as  from  excessively  hot  baths,  scalding,  and 
burning;  sudden  and  violent  variations  in  the  surrounding  temperature; 
painful  wounds  and  foreign  bodies;  herpes  vaginalis;  phimosis;  pressure 
on  the  testicles;  irritation  of  the  genitals  from  irritation  of  yarn,  etc. 
Carious  conditions  of  the  mastoid  and  disease  of  the  middle  ear  may  be 
associated  with  convulsions  without  evidence  of  signs  of  meningeal 
trouble.  Reflex  conditions  in  the  gastro-intestinal  tract  aftect  a  large 
class  of  cases. 

The  eruption  of  the  teeth  is  given  as  an  important  factor  by  many 


1  Osier:  Modern  Medicine,  1915,  2d  ed.,  vol.  v. 


304  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

authorities.  Ulcerative  conditions  of  the  oral  mucous  membrane, 
enlarged  tonsils,  and  nasopharyngeal  adenoids  may  act  in  a  purely 
reflex  manner,  or  assist  in  the  lowering  of  general  nutrition  and  nerve 
tone. 

Overloading  the  stomach  of  a  person  with  a  finely  balanced  nervous 
system  with  indigestible  food  may  be  the  determining  factor  in  a  con- 
vulsive seizure  not  only  in  childhood  but  at  any  period  of  life.  The 
ingestion  of  irritating  substances,  such  as  alcohol,  reacts  in  a  like 
manner,  as  may  also  intestinal  auto-intoxication  with  chronic  consti- 
pation, intestinal  parasites  of  various  kinds,  reflex  conditions  in  the 
genito-urinary  tract,  catarrhal  conditions,  congenital  anomalies,  blad- 
der and  kidney  stones,  and  congenital  kidney  diseases. 

While  given  recognition  in  common  with  other  reflex  irritations, 
the  full  importance  of  pathological  dentition  is  evidently  not  appre- 
ciated. Although  primarily  a  physiological  process,  dentition  is 
frequently  disturbed.  As  it  occurs  at  about  the  period  of  rapid  brain 
development,  which  results  in  temporarily  increased  sensibility  on  the 
part  of  the  individual,  the  unusual  sensitiveness  to  irritation  of  the 
brain  cells  and  nerve  structures  at  this  period  opens  the  way  for  grave 
manifestations  of  delayed  or  disturbed  tooth  eruption.  Study  of  the 
illustration  on  page  60  will  show  that  the  rapidly  organizing  mass  of 
cells  from  which  the  tooth  pulp  is  forming  becomes  daily  more  sensitive 
to  pressure  from  the  sharp  borders  of  the  calcifying  tooth  crowns, 
when  the  resistance  of  toughened  overlying  gum  tissues  makes  counter- 
pressure  against  the  force  which  would  otherwise  naturally  crowd  the 
erupting  dental  organs  toward  the  surface.  Such  pressure  occurring  at 
a  time  of  unusual  individual  sensitiveness  must  and  does  exert  a  very 
important  influence  in  precipitating  ill  results  for  which  there  are  often 
predisposing  inherent  tendencies.  Many  symptoms  of  both  central 
and  peripheral  irritation  which  appear  under  these  conditions  may  thus 
be  accounted  for. 

Many  infants  have  been  relieved  in  the  author's  practice,  and  prompt 
and  eflHcient  relief  has  been  reported  by  many  others,  or  at  least  the 
way  to  recovery  from  grave  infantile  nervous  states  has  been  pointed 
out,  by  the  simple  operation  of  opening  the  toughened  gum  tissue 
covering  tooth  cro\Mis.  For  this  reason  the  procedure  is  certainly 
worthy  of  due  consideration  and  adoption  as  a  prophylactic,  even 
though  it  may  not  always  be  a  curative  measure. 

(For  further  consideration  of  the  eftect  of  buccal  irritation  see 
page  280.) 

Chorea,  St.  Vitus'  Dance. — This  disease  is  manifested  by  irregular 
muscular  contraction  resulting  in  purposeless  movements  sometimes 
associated  with  psychic  manifestations. 

Etiology.— Its  predisposing  cause  is  a  neurotic  tendency  represented 
by  lack  of  equilibrium  in  the  nervous  inhibitory.  The  exciting  cause 
may  be  an  infectious  agent  or  its  toxin  or  some  affection  of  the 
central  nervous  system.    Age  seems  to  bear  an  important  relation 


SPASMODIC  NEUROSES  305 

in  this  regard,  since  it  most  often  occurs  in  childhood,  particularly 
in  the  later  years  during  adolescence.  Osier's  record  of  535  cases 
shows  that  33  occurred  in  the  first  hemidecades,  228  in  the  second, 
and  62  in  the  fourth.^ 

Granasso-  says  that  central  auto-intoxication  following  emotional 
disturbance  may  account  for  some  cases. 

Symptoms. — Choreic  movements  are  spasmodic,  unexpected,  and 
although  they  cannot  be  checked  by  an  effort  of  will,  are  likely  to  be 
increased  by  excitement,  concentration  of  attention,  and  efforts  to 
control  the  muscles  involved.  Such  muscular  twitching  is  generally 
of  quick  transition  and  does  not  exhaust  the  patient,  but  in  rare  cases 
it  becomes  so  violent  and  continuous  as  to  jeopardize  the  patient's  life. 
Any  of  the  muscles  of  the  body  may  be  involved,  but  those  of  the  face 
and  extremities  are  most  commonly  aflfected. 

IMovement  of  the  eyelids,  lips,  cheeks,  and  tongue  occurs  suddenly. 
The  facial  appearance  may  thus  be  distorted  into  a  grimace,  or  there 
may  be  snapping  together  of  the  jaws,  grinding  of  the  teeth,  or  evi- 
dences of  the  involvement  of  the  respiratory  and  laryngeal  muscles. 

In  a  large  proportion  of  cases  the  affection  is  unilateral  and  occurs 
upon  the  right  side  more  frequently  than  the  left.  Mental  irritability, 
as  a  rule,  becomes  noticeable  early  in  disease.  It  occurs  most  fre- 
quently in  childhood,  but  may  appear  in  adult  life. 

Prognosis. — The  prognosis  is  often  unfavorable.  Recoveries  are 
estimated  at  about  5  per  cent.  Hopeful  conditions  are  when  treat- 
ment can  be  begun  at  a  sufficiently  early  date  by  the  removal  of  some 
known  irritating  cause  or  where  surgical  treatment  is  successful.  Its 
duration  is  uncertain.  Anemias,  mental  excitement,  rheumatism, 
and  endocarditis  render  its  aspect  more  serious. 

Treatment. — Since  chorea  is  a  symptom  and  not  a  disease  per  se, 
its  treatment  must  be  directed  to  the  cause  of  the  choreic  symptoms 
which  should  be  carefully  sought  for  in  every  case.  Every  possible 
form  of  peripheral  irritation  or  any  pathological  state  that  might 
have  an  etiological  influence  must  be  duly  corrected  or  treated;  par- 
ticularly is  this  true  of  the  class  of  cases  which  give  evidence  of  etio- 
logical factors  which  are  the  subject  of  our  special  interest,  such  as  those 
described  in  connection  with  convulsions,  epilepsy,  etc.  It  of  course 
must  be  understood  that  every  effort  should  be  made  to  build  up  the 
general  system  and  to  favor  psychic  healthful  influences.  The  admin- 
istrations of  medicines  must  be  directed  to  the  improvement  of  general 
conditions  that  might  have  predisposing  influences.  Fowler's  solution, 
3-drop  doses,  three  times  a  day,  increased  one  drop  daily  until  a  puffi- 
ness  of  the  eyelids,  nausea,  or  pain  indicates  its  limit,  and  chloretone, 
5  grains  three  times  a  day,  are  highly  recommended  remedies.  The 
aspect  of  this  disease  which  most  concerns  our  subject  is  given  on  page 
307,  in  connection  with  treatment  of  epilepsy  and  other  neuroses. 

1  Copezinski:  Re\aew  Neurologique,  1903,  p.  1157. 

2  Riforma  Medica,  1903,  p.  429. 
20 


306  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

Facial  Spasm. — Facial  spasm  is  a  spasmodic  twitching  of  the  muscles 
supplied  by  the  facial  nerve.  It  is  a  disease  of  adult  life,  and  does  not 
usually  develop  until  after  the  age  of  forty  years. 

Etiology. — Sensory  rather  than  motor  irritations  are  believed  to  be 
its  causes.  Local  disease  of  the  eyelids  or  visual  strain  of  the  ocular 
muscles  are  held  accountable  in  most  cases  for  the  act  of  winking. 
Irritation  of  the  trigeminal  nerve  at  some  point  or  points  in  its  distri- 
bution are  the  most  frequent  causes  of  the  sudden  contractions  in  the 
facial  muscles.  Therefore  conditions  which  might  lead  to  irritation 
from  teeth  and  other  parts  of  the  mouth,  nose,  throat,  or  scalp  may  be 
active  etiological  factors. 

Tic. — Effort  has  recently  been  made  to  limit  the  meaning  of  this 
quite  broadly  used  term  to  the  definition  given  by  Brissaud  and 
JNIeige:^  "A  primary  act  caused  by  an  external  irritation  or  b}^  an 
idea  coordinated  for  a  special  end." 

Etiology. — The  habit  of  the  act  is  acquired  by  constant  repetition, 
and  then  occurs  involuntarily.  The  impulse  is  uncontrollable,  but  the 
act  can  be  controlled  by  sufficient  effort.  Such  habits  of  abnormal 
muscular  movement  are  easily  acquired  by  children  who  are  imitative 
or  excited  by  slight  sensations. 

Symptoms  and  Differential  Diagnosis  of  Facial  Spasm  and  Tic— These 
affections  have  a  s}7nptomatic  similarity  which  Patrick-  distinguishes 
by  calling  attention  to  six  contrasting  points.  Grouped  in  opposite 
columns  for  the  sake  of  con^-enience  these  are  as  follow?: 

TIC.  FACIAL  SPAS-M. 

1.  Tic  is  more  common  than  spasm  and  1.  More  rare  disposition  and  tempera- 
affects  nervous  and  neuropathic  indi\T.d-         ment  not  significant. 

uals. 

2.  Tic  is  a  volitional  movement  (even  2.  Is  a  real  spasm,  isolated  and  con- 
when  automatic  and  subconscious),  -with  fined  to  motor  innervation  of  the  face, 
extensive  psychic  sensorj'  associations. 

3.  Subject  to  control  of  the  will  and  3.  Devoid  of  voluntary-  or  involuntary- 
involuntary    emotion    or    intellectual    in-  control. 

flue  nee. 

4.  Physiological.  4.  Anatomical. 

5.  Has  the  appearance  of  natural  move-  5.  Unnatural  in  appearance  and  can- 
ment.  not  be  voluntarily  imitated. 

6.  Does  not  necessarily  cause  speech  6.  Speech  or  other  physiological  action 
inability  during  spasm.  is  impossible. 

Treatment  of  Facial  Spasm  and  Tic. — The  treatment  of  facial  spasm 
and  tic  depends  upon  recognition  of  their  essential  differences.  The 
relief  of  every  possible  soiu-ce  of  peripheral  irritation  in  the  region 
of  the  involved  muscles  upon  the  one  hand  and  control  of  habit  upon 
the  other. 

Epilepsy. — Epilepsy  is  a  disease  or  disorder  afflicting  the  brain, 
characterized  by  recurrent  paroxysms  which  are  abrupt  in  appearance, 

1  Starr:  Nervous  and  Mental  Diseases,  after  Jour,  de  med.,  Paris,  1905.  et  Chir.  pract., 
January  24,  1894,  and  Traite  de  med.,  tome  x,  p.  330. 

2  Jour.  Nerv.  and  Ment.  Dis.,  1909. 


SPASMODIC  NEUROSES  307 

variable  in  duration,  but  generally  short,  and  in  which  there  is  impair- 
ment or  loss  of  motor  coordination,  with  or  without  convulsions. 

Etiology. — The  etiological  factors  which  have  been  associated  with 
this  disease  are  almost  without  number.  There  is  undoubtedly  a 
primary  neurotic  tendency  in  all  such  patients,  and  in  large  numbers 
of  them  direct  heredity  is  in  evidence,  either  through  epileptic 
parents  or  family  history,  showing  insanity,  alcoholism,  s}T)hilis,  or 
other  constitutional  diseases.  Personal  history  frequently  shows 
record  of  spasms  in  infancy,  difficult  dentition,  traumatic  injuries 
to  the  head  or  spine,  and  acute  infectious  or  other  diseases  of  childhood. 
All  of  these  are  looked  upon  as  predisposing  conditions.  Electrical 
shock,  arteriosclerosis,  brain  disease,  insanity,  nephritis,  disorders  of 
menstruation,  pregnancy,  and  maternity  occasionally  bear  a  close 
relation  to  the  onset  of  epileptic  symptoms.  Affections  of  the  heart 
are  also  frequently  found  in  these  subjects.  Hydrocephalus  is  some- 
times present  in  incurable  cases.  Under  the  heading  of  INIiscellaneous 
Causes,  Spratling  sums  up  questions  which  are  of  vital  importance 
from  our  present  point  of  view  in  the  following  manner: 

"  Given  a  marked  hereditary  tendency,  there  are  numerous  agencies 
capable  of  causing  epileptic  con\'ulsions  in  addition  to  those  mentioned. 
Gastro-intestinal  disorders  have  not  received  the  consideration  they 
deserve.  Intestinal  toxemia  may  cause  convulsions  in  two  ways, 
either  by  approximating  the  peripheral  nerves  (visceral)  in  that  locality 
or  by  the  absorption  of  certain  toxic  substances." 

Protein  poisoning  and  the  influence  of  vagotonic  conditions  in  the 
light  of  recent  investigations  assumes  an  increased  importance  in  this 
relation. 

Pathology. — The  pathology  is  not  clearly  defined  beyond  certain 
theories  with  reference  to  organic  diseases,  toxemia,  and  the  effect  of 
well-known  nerve  irritations  or  excitants  of  unusual  nervous  activity. 

Symptoms. — In  a  considerable  number  of  cases  the  symptoms  are 
preceded  by  an  aura,  or  conscious  sensation,  which  in  time  becomes 
a  sort  of  warning  of  an  attack.  Detailed  consideration  of  the  many 
forms  in  which  symptoms  of  this  affection  appear  would  be  quite 
beyond  our  present  purpose.  All  may  be  grouped  in  two  chief  divi- 
sions, known  as  petit  mal,  or  slight  attacks  evidenced  by  loss  of  con- 
sciousness lasting  for  a  short  time  and  accompanied  by  a  variety  of 
symptoms  but  without  actual  con\iilsion,  and  grand  mal,  accompanied 
by  loss  of  consciousness,  a  considerable  period  of  stupor  and  convulsions, 
with  loss  of  memory  during  the  attack.  Many  of  these  patients  show 
stigmata  of  degeneracy,  as  explained  by  Talbot  and  others,  and  have 
abnormal  contours  of  the  skull,  peculiarly  shaped  ears,  eyes,  hands,  feet, 
and  other  features.  High  arched  palatal  vaults  and  irregular  teeth  are 
extremely  common  and  worthy  of  due  consideration,  and  such  subjects 
are  almost  invariably  "  tooth  grinders." 

Treatment. — Treatment  should  include  careful  search  for  and  relief 
by  proper  correction  of  every  possible  form  of  peripheral  irritation 


308 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


in  the  jaws  and  mouth.  Long  before  the  onset  of  the  characteristic 
sjTmptoms  in  neurotic  indi\iduals,  even  though  epileptic  tendencies 
may  not  be  suspected,  it  should  be  a  routine  practice  to  warn  the 
parents  of  every  growing  child  with  contracted  dental  arches  and  high 
palatal  vault,  or  the  teeth  erupting  in  such  irregular  form  as  to  pre- 
dispose to  this  kind  of  development  with  its  inevitable  ill  effect  in 
narrowing  the  nose  and  leading  the  intranasal  deformities  and  diseases, 
that  expansion  particularly  the  upper  dental  arch,  by  separation  of  the 
maxillae  and  thus  widening  the  nose  is  imperatively  necessary.  When 
there  is  evidence  of  the  beginning  of  this  affection,  careful  search 
should  be  made  for  unerupted  teeth,  and  every  missing  tooth  properly 


Fig.  157. — Radiograph  of  an  unerupted  impacted  third  molar,  the  removal  of  which 
relieved  a  young  man,  nineteen  years  old,  of  attacks  of  unconsciousness,  with  muscular 
twitching,  preceded  by  an  aura,  and  diagnosed  as  epilepsy. 


accounted  for,  and  if  necessary  its  presence  and  situation  or  absence 
demonstrated  by  carefully  taking  radiographs  (Fig.  157).  The  possi- 
bility of  supernumerary  teeth  should  always  be  borne  in  mind  when 
none  are  missing  from  the  regular  set.  Pulp  stones,  fillings  that  may 
cause  chronic  irritations  of  dental  pulps,  carious  cavities,  and  tooth 
crowns  which  may  expose  their  pulps  to  chronic  irritation,  the  abraded 
occlusal  surfaces  of  teeth  which  indicate  tooth-grinding  habits,  chronic 
pericemental  and  other  similar  affections  should  be  sought  for  with 
great  care  and  properly  treated  if  any  such  should  be  discovered. 

When  traumatic  or  other  brain  lesions  exist,  surgical  treatment 
by  location  of  the  primarily  affected  area  and  removal  of  the  cause  if 


SPASMODIC  NEUROSES  309 

possible,  gives  the  only  possibility  of  permanent  relief.  Even  Avith 
cases  so  treated  there  i  ahvays  an  element  of  uncertainty,  because  it  is 
well  known  that  almost  any  operation  in  some  subjects  may  cause  a 
cessation  of  the  attacks  for  considerable  periods  of  time,  though  no 
real  permanent  good  may  have  been  accomplished. 

Fenestration  of  the  SkiiU. — The  removal  of  intracranial  pressure 
by  this  and  similar  expedients  is  a  procedure  that  is  undoubtedly 
growing  in  favor  among  surgeons  for  the  relief  of  affections  of  various 
kinds,  and  in  certain  forms  of  epilepsy  might  be  expected  to  afford 
unusual  relief. 

Other  treatment  in  a  general  way  includes  building  up  the  strength 
and  normal  vital  energy  of  the  patient  by  good  hygienic  care,  dietetic 
regulations,  and  favorable  psychic  influences,  baths,  massage,  daily 
flushing  of  the  bowels,  appropriate  treatment  for  improvement  of 
intestinal  conditions,  and  the  administration  of  bromides,  which 
should  be  given  ;n  large  doses. 

It  is  claimed  by  Prior  and  Jones^  that  there  is  a  diminished  amount 
of  free  calcium  in  the  blood  of  epileptics,  and  that  they  may  be  bene- 
fited by  the  administration  of  calcium.  Wherry  and  Oliver-  recom- 
mend the  administration  of  calcium  combined  with  bromides. 

\Yith  reference  to  all  of  the  spasmodic  affections  such  as  infantile 
spasm,  chorea,  epilepsy,  and  similar  diseases,  the  purpose  of  giving 
them  consideration  in  this  volume  is  to  emphasize  the  features  which 
are  properly  connected  with  the  effect  and  relief  of  dental  and  oral 
irritation.  Therefore  no  attempt  at  detailed  description  of  the  many 
methods  of  treatment  of  these  is  undertaken. 

The  Relations  of  the  Mouth  and  Teeth  to  Spasmodic  Neuroses. — 
It  is  a  significant  fact  that  the  onset  of  the  symptoms  of  chorea,  epi- 
lepsy, and  kindred  affections  in  the  great  majority  of  cases  occurs 
at  periods  of  development  termed  by  Talbot  "Periods  of  Stress." 
Kierman  pointed  out  that  they  are  coincident  with  the  development 
and  eruption  of  both  temporar}-  and  permanent  sets  of  teeth,  particu- 
larly at  about  the  age  of  five  or  six  years,  when  the  first  permanent 
molar  is  erupted.  He  showed  that  in  persons  of  unstable  nervous 
system  their  neurotic  tendencies  predispose  to  these  affections.  Irri- 
tation from  pressure  of  the  sharp  borders  of  the  undeveloped  open  ends 
of  the  growing  roots  against  the  underlying  nerve  structures  is  caused 
by  resistance  of  overlying  structures  in  the  process  of  tooth  eruption  as 
previously  described  (page  59),  or  by  the  crowding  of  malposed  teeth 
in  contracted  dental  arches.  On  account  of  the  bell-shape  of  the  tooth 
crowns  and  the  conical  form  of  the  roots  there  results  a  slight  nerve 
stretching  when  the  force  of  the  jaws  is  applied  upon  these  crowded 
teeth.  Thus  a  more  or  less  continuous  nerve  irritation  arises,  which 
at  this  time  of  weakened  resistance  intensifies  already  existing  tenden- 

1  Med.  JoTir.,  Australia,  March  4,  1916,  and  Practical  Medicine  Series,  page  19,  Ner- 
vous and  Mental  Diseases. 

*  Joui.  Am.  Med.  Assn.,  October  7,  1916. 


310  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

cies  and  precipitates  attacks  of  these  affections.  Kiernan  also  expresses 
the  behef  that  if  such  persons  could  be  guarded  from  irritation  of  this 
character  at  such  periods,  choreic  and  epileptic  attacks  would  be 
avoided  in  many  instances,  for  with  increased  age  and  natural  cor- 
rection of  the  irritation  the  tendency  would  probably  disappear  and 
disorders  of  that  character  not  be  manifested. 

Spratling^  states:  "Difficult  dentition  probably  never  acts  as  an 
unqualified  cause  when  not  influenced  by  another  agency,  but  there 
is  little  doubt  that  when  dentition  becomes  pathological  in  a  strongly 
tainted  neuropathic  subject  it  may  cause  a  t}^e  of  convulsion  which, 
if  permitted  to  go  unchecked,  may  evidently  pass  into  a  more  or  less 
true  form  of  the  disease.  Xo  one  would  think  of  designating  as  epilepsy 
a  single  convulsion  caused  by  painful  dentition  in  a  rachitic  child, 
accompanied  by  high  temperature,  irritability,  and  great  restlessness. 
But  should  there  be  several  con\'ulsions  which  continue  with  more  or 
less  regularity,  showing  the  essential  characteristics  of  the  true  disease, 
including  the  aura,  the  epileptic  cry,  and  the  various  postconclusive 
phenomena,  common  reason  would  lead  us  to  designate  them  as 
epileptic.  So  while  dentition  may  never  be  an  unqualified  factor, 
it  has  under  special  conditions  the  power  to  incite  a  type  of  convulsion 
that  may  pass  into  epilepsy  so  far  as  the  general  results,  by  prognosis, 
and  the  treatment  are  considered.  In  30  cases  the  palsy  originating 
between  the  sixth  and  eleventh  month  of  life,  and  all  persons  known 
to  the  writer,  difficult  dentition  was  the  assigned  cause." 

In  this  connection  it  should  be  borne  in  mind  that  delayed  tooth 
eruption,  particularly  the  third  molars,  may  occur  and  be  a  source 
of  serious  irritation  at  later  periods  of  life.  One  of  the  author's 
patients,  a  young  lady,  aged  twenty-six  years,  suft'ered  from  intense 
and  more  or  less  continuous  pain  at  various  points  of  distribution 
of  the  fifth  nerve  on  the  left  side,  accompanied  by  choreic  movement 
of  the  muscles  of  the  arm  and  leg  upon  the  affected  side,  with  occasional 
manifestations  in  the  facial  region.  It  was  found  that  the  crown 
of  the  left  superior  third  molar  was  crowded  between  the  roots  of  the 
second  molar  upon  the  same  side,  and  the  left  lower  third  molar  was  so 
impacted  as  to  cause  continued  crowding  of  the  lower  teeth.  The 
removal  of  these  teeth  gave  a  measure  of  relief,  although  the  long 
continuance  of  the  sjinptoms  before  this  cause  was  discovered  had 
undoubtedly  led  to  general  involvement  which  made  immediate  cure 
impossible. 

Such  conditions  are  very  common  causes  of  nervous  disturbance. 
Large  numbers  of  the  author's  patients  with  varying  symptoms  of 
neurasthenia,  chronic  neuralgia  of  the  head  and  face,  and  other 
neuroses  have  been  relieved  or  completely  cured  by  the  discovery  and 
removal  of  malposed  or  impacted  teeth  delayed  in  their  eruption.  (For 
further  references  see  pages  60  to  65.) 

1  Osier:  Modern  Medicine,  1915,  2d  ed.,  vol.  v. 


7.20 

A.M. 

7.30 

A.M. 

7.45 

A.M. 

8.00 

A.M. 

SPASMODIC  NEUROSES  311 

A  case  of  Jacksonian  epilepsy  in  a  man,  aged  twenty-two  years, 
is  an  example  of  the  effect  of  surgical  maxillary  separation  in  certain 
epileptics. 

History. — Nervous  troubles  began  in  1904.  The  seizures  started 
with  spasmodic  contractions,  or  numbness,  sometimes  partial  or 
complete  unconsciousness.  The  symptoms  usually  began  in  the  right 
foot  and  ascended  to  the  head,  and  across  the  forehead,  but  only  in  the 
more  profound  attacks  was  the  left  side  involved.  An  extract  from 
the  records  of  St.  Mary's  Hospital  shows  the  frequency  of  these 
attacks  at  the  time  of  his  entrance,  during  one  day  and  one  night. 
The  record  for  every  day  and  night  was  practically  the  same: 

RECORD. 

7.10  A.M.     Slight  spell  lasting  thirty  seconds.    Muscular  twitching 
of  left  arm  and  eyes.     Sleeping. 
Slight  spell  lasting  twenty  seconds. 
Twitching  of  left  side. 
Slight  spell  lasting  fifteen  seconds.     Twitching  of  left 

limb  and  arm. 
Slight  spell  lasting  twenty  seconds.    Twitching  of  left 
arm. 
8.05  A.M.     Slight  spell  lasting  twenty  seconds.    Twitching  of  left 

and  right  limb. 
8.30  A.M.     Slight  spell  lasting  thirty  seconds.     Muscular  twitching 

of  eyes  and  left  side. 
8.50  A.M.     Severe  spell  lasting  forty  seconds.   Twitching  of  muscles. 

8.54  A.M.  Slight  spell  lasting  twenty  seconds.  Muscular  twitch- 
ing of  left  limbs. 

8.57  A.M.  Slight  spell  lasting  twenty  seconds.  Muscular  twitch- 
ing of  face. 

9.10  A.M.    Slight  spell  lasting  ten  seconds.    Twitching  of  feet. 

9.20  A.M.  Slight  spell  lasting  thirty  seconds.  Twitching  of  left 
limbs. 

9.30  A.M.  Slight  spell  lasting  forty  seconds.  Muscular  twitching 
of  eyes  and  left  arm. 

9.45  A.M.  Slight  spell  lasting  fifteen  seconds.  Muscular  twitching 
of  feet  and  left  arm. 

9.55  A.M.  Slight  spell  lasting  thirty  seconds.  Twitching  of  left 
limbs. 

10.00  A.M.     Slight  spell  lasting  five  seconds.     Twitching  of  left  hand. 
10.07  A.M.     Slight  spell  lasting  forty  seconds.     Muscular  twitching 

of  feet  and  eyes. 
10.10  A.M.    Slight  spell  lasting  twenty  seconds.    Twitching  of  left 

limbs. 
10.15  A.M.    Slight  spell  lasting  fifteen  seconds.    Throwing  left  foot 

from  body. 


312 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


10.20  A.M.    Slight  spell  lasting  twenty  seconds.     Twitching  of  left 

limbs. 
10.30  A.M.    Slight  spell  lasting  ten  seconds.    Twitching  of  limbs. 
10.34  A.:^i.    Slight  spell  lasting  thirty  seconds.     Muscular  twitching 

of  eyes. 
10.43  A.M.     Severe  spell  lasting  fifty  seconds.     Muscular  twitching 

of  limbs,  tossing  about,  cough  at  intervals. 
10.50  A.M.     Slight  spell  lasting  thirty  seconds.     Twitching  of  left 

limbs,  pulling  at  clothing. 
11.00  A.M.     Slight  spell  lasting  ten  seconds.     Twitching  of  eyes. 
1 1.10  A.M.     Slight  spell  lasting  twenty  seconds.    Twitching  of  limbs. 
11.20  A.M.     Slight  spell  lasting  five  seconds.     Twitching  of  eyes. 
11.30  A.M.     Slight  spell  lasting  thirty  seconds.     Twitching  of  limbs. 

This  record  is  typical  of  his  other  days  up  to  the  time  of  the  opera- 
tion. His  maxillary  bones  were  separated  through  an  incision  under 
the  upper  lip.  A  wide  separation  was  immediately  effected,  and 
pressure  with  the  appliance  continued  by  tightening  the  nut  for  several 
days,  until  he  said  it  felt  like  a  gale  of  wind  through  his  nose  when  he 
breathed.  Following  the  operation  diplopia  was  noted.  The  double 
vision  soon  disappeared  and  in  the  course  of  three  or  four  days  the 
attacks  began  to  be  less  frequent,  and  had  ceased  altogether  by  the 
ninth  day,  when  he  was  discharged  from  the  hospital. 


Fig.  158. — An  epileptic  young  woman  who  seems  to  have  been  entirely  relieved  by 
this  surgical  immediate  separation  of  the  maxillae.  Shows  a  type  of  face  that  indicates 
the  need  of  this  treatment. 


He  was  quite  free  from  further  trouble,  grew  strong  and  well  and 
increased  in  flesh,  for  a  period  of  about  two  years.  At  this  time  it  was 
learned  that  he  had  had  more  or  less  recurrence  of  the  attacks.     As  he 


HYSTERIA  313 

has  not  reported,  the  author  is  unable  to  state  the  character  or  duration 
of  the  rehipse. 

The  expression  of  his  eyes  and  his  whole  appearance  changed, 
as  the  ett'ect  of  the  improved  respiratory  condition  became  apparent. 

All  eases  that  have  been  treated  in  this  way,  thus  far,  have  evidenced 
improvement,  but  some  have  not  been  completely  relieved  for  any 
considerable  period  of  time. 

The  young  women  shown  in  Fig.  158  is  at  the  present  time  and  for 
several  weeks  has  been  free  from  epileptic  seizures,  which  up  to  the 
time  of  surgical  maxillary  separation  for  intranasal  enlargement  had 
gradually  been  becoming  more  frequent  and  serious  in  their  character. 
It  seems  unnecessary  to  make  an  attempt  to  report  these  and  other 
cases  in  detail,  for  this  brief  reference  is  only  intended  to  call  attention 
to  the  possibilities  of  intelligent  oral  treatment  as  a  helpful  measure 
for  the  relief  of  at  least  some  of  the  sufferers  from  epilepsy  and  similar 
affections,  but  not  in  any  sense  as  a  sovereign  remedy.  When  indi- 
cated by  high  narrow  palates,  contracted  dental  arches,  and  nasal 
conditions  which  favor  the  habit  of  mouth-breathing,  this  should  be  a 
routine  measure  in  all  cases  of  epilepsy  to  prepare  for  and  increase  the 
efficiency  of  any  other  treatment  that  may  be  given. 

Bacillus  Einlepticiis. — Dr.  C.  A.  L.  Reed,^  of  Cincinnati,  claims  to 
have  discovered  that  the  cause  of  epilepsy  is  a  bacillus  which  he  has 
isolated  and  named  the  "Bacillus  epilepticus." 

Terhune  reports  that  the  Bacillus  epilepticus  has  been  isolated 
from  75  per  cent,  of  24  of  the  cases  of  epileptics,  from  which  cultures 
were  made  during,  or  immediately  following  seizures,  and  18  in  whom 
no  convulsions  had  occurred  for  several  days.  Wherry,  Oliver,  Cana- 
van,  and  other  investigators  have  failed  to  identify  this  bacillus,  and 
its  etiological  identity  with  epilepsy  is  not  yet  generally  accepted. 
Reed  has  also  reported  a  large  number  of  cases  in  which  he  believes  a 
cure  has  been  effected  by  operations  to  overcome  colonic  stasis. 

HYSTERIA. 

Hysteria  is  a  neurosis  characterized  by  abnormal  cessations,  a 
morbid  susceptibility  to  emotions,  and  inability  to  restrain  their 
manifestations. 

Etiology. — Hysteria  plays  a  part  in  nervous  affections  of  the  mouth 
and  associated  parts,  as  in  other  regions  of  the  organism  as  a  whole. 
Its  extended  consideration  would  be  outside  the  province  of  this  work, 
except  insofar  as  general  conclusions  may  be  indicated  to  avoid  error 
in  diagnosis  and  treatment. 

Symptoms. — Babinski^  states  that  the  reason  for  the  excessive 
extension  of  the  symptomatology  of  hysteria  is  due  to  three  leading 

1  Practical  Medicine  Series,  Nerv.  and  Ment.  Dis.,  1916,  p.  19. 

2  La  Semaine  Medicale,  January  6,  1909.  Babinski's  articles  on  the  Dismemberment 
of  Traditional  Hysteria  Pithiatism,  published  in  La  Semaine  Medicale,  as  the  first  paper 
in  1909,  translated  by  Charles  Gilbert  Chaddock,  and  published  in  the  Interstate  Medical 
Journal,  March,  1909. 


314  NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 

causes;  (1)  Errors  of  diagnosis,  many  organic  cases  being  considered 
hysterical;  (2)  failure  to  detect  simulation;  (3)  failure  to  distinguish 
various  nervous  states  which  ought  to  be  distinguished  one  from 
another. 

He  differentiates  between  two  great  groups  of  symptoms,  as  (1) 
those  which  can  be  produced  by  suggestion,  and  (2)  those  which  can- 
not be  so  produced. 

Symptoms  which  may  be  produced  by  suggestion,  and  are  therefore 
hysterical,  are:  Convulsive  crises,  paralysis,  contractures  of  every 
sort  and  location,  various  tremors,  choreic  movements,  disturbances 
of  phonation  and  of  respiration,  sensory  disturbances  such  as  anes- 
thesia and  hyperesthesia.  Symptoms  not  capable  of  being  produced 
by  suggestion,  and  therefore  not  hysterical,  are:  Exaggeration  or  loss 
of  the  tendon  reflexes,  vasometer,  secretory,  and  trophic  changes, 
hemorrhage,  anuria,  albuminuria,  and  fever. 

Diagnosis. — It  is  sometimes  very  difficult  to  determine  whether 
pain  in  the  teeth  or  other  points  of  distribution  of  the  fifth  nerve,  spas- 
modic affections  of  the  muscles  and  other  similar  disturbances  in  the 
region  of  the  mouth  are  wholly  or  even  partially  of  hysterical  origin 
or  their  apparent  gravity  exhibited  from  the  same  cause.  Too  often 
real  though  hidden  pathological  conditions  are  overlooked,  and  through 
imperfect  diagnoses  there  is  failure  to  give  relief,  and  much  consequent 
suffering  because  the  symptoms  have  been  erroneously  pronounced 
imaginary  after  superficial  examination. 

On  the  other  hand,  it  has  not  infrequently  occurred  that  teeth  have 
been  needlessly  extracted,  pulps  of  teeth  removed,  useful  fillings  or 
other  dental  work  destroyed,  and  no  local  real  pathological  conditions 
of  the  parts  so  treated.  No  set  rule  for  the  avoidance  of  such  errors 
can  be  given,  and  the  operator  must  necessarily  rely  upon  his  own 
knowledge  and  skill  as  a  diagnostician  to  determine  indications  of 
actual  disease,  supplemented  by  good  judgment  in  determining  the 
mental  attitude  of  each  patient.  With  the  foregoing  division  of  affec- 
tions that  might  or  might  not  be  evidence  of  hysteria  as  a  guide, 
differentiation  will  be  much  simplified. 

NEURASTHENIA. 

Neurasthenia  may  be  defined  as  debility  or  impaired  activity  of 
the  nerves  or  of  the  nervous  system  generally,  nerve  causation. 

Etiology. — ^The  leading  causes  of  neurasthenia  summed  up  according 
to  Schofield,^  who  is  in  accordance  with  other  writers,  are: 

1.  Poisons  from  influenza,  syphilis,  enteritis,  dyspepsia,  alcohol, 
drugs,  zymotic  and  other  diseases. 

2.  Malnutrition. 

3.  Fatigue  from  overwork,  worry,  insomnia,  pain,  sexual  excesses, 
suppression. 

1  British  Med.  Jour.,  September  19,  1908;  Practical  Medicine  Series,  1909,  x,  31. 


NEURASTHENIA  315 

4.  Emotional  strain  from  shock,  grief,  accidents,  religion,  love,  etc. 

5.  Indirect  causes,  as  enteroptosis,  floating  kidney,  eye-strain,  also 
bad  environment,  suggestion,  and  other  psychic  factors. 

The  principal  predisposing  cause  is  hereditary.  Psychologically 
neurasthenia  is  a  disease  of  exhaustion  of  the  higher  nerve  centers, 
since  poisoning  produces  toxic  eft'ects  similar  to  those  from  overwork. 
To  weakness  of  these  centers  by  fatigue  or  poison  from  some  of  the 
above  causes  we  may  attribute  even  the  most  psychical  symptoms 
of  this  disease,  such  as  "phobias"  and  "obsession,"  provided  always 
that  the  patient  be  free  from  any  underlying  mental  taint. 

To  these  should  be  added,  for  our  special  purpose,  conditions  of  the 
mouth  M'hich  can,  and  do  in  many  instances,  predispose  or  directly 
or  indirectly  contribute  to  any  or  all  of  the  foregoing  etiological  influ- 
ences. 

It  is  well  known  that  there  is  no  more  common  factor  associated 
with  the  cause,  of  stomach  and  intestinal  disturbances  and  malnu- 
trition than  diseased,  uncleanly,  or  defective  teeth.  The  question  of 
food  trituration  in  mastication  and  its  proper  insalivation  from  active 
proper  use  of  the  jaws,  the  necessity  of  sufficiency  or  insufficiency  of 
ptyalin  from  the  saliva  for  assistance  in  the  digestion  of  starch  foods, 
and  the  effect  of  all  these  combined  influences  upon  metabolism  are 
so  obvious  as  to  make  elaborate  discussion  unnecessary.  The  same 
may  be  said  of  bacterial  influences,  exerted  by  pathogenic  micro- 
organisms from  uncleanly,  decaying,  or  diseased  tooth  roots,  gums, 
and  other  structures  being  carried  through  the  intestinal  tract  and 
focal  infection  via  other  channels.  It  is  also  well  understood  that 
there  is  no  more  active  or  constant  poison  in  general  disease  than  the 
autotoxemia  which  goes  hand  in  hand  with  these  conditions.  The 
question  of  fatigue,  however,  requires  distinct  consideration  on  account 
of  the  fact  that  tooth  grinding,  especially  at  night,  is  an  almost  con- 
stant symptom  of  general  nervous  states  and  particularly  neurasthenia. 
On  account  of  the  teeth  being  crowded  in  the  dental  arch,  imperfect 
occlusion  through  loss  of  teeth,  malposition,  or  other  conditions  that 
may  tend  to  produce  irritation,  the  habit  of  clinching  and  grinding 
teeth  is  induced.  Patients  are  seldom  ready  to  admit  the  fact  until 
absolutely  proved,  because  the  habit  is  an  unconscious  one,  active 
at  subconscious  moments  in  the  da^^time,  but  more  particularly  at 
night  during  sleep,  which  is  therefore  not  sufficiently  restful.  The 
constant  exertion  of  the  muscles  of  mastication  with  the  incident 
brain  cell  stimulation  prevents  perfect  rest,  which  in  the  course  of 
time  may  undoubtedly  lead  to  quite  as  grave  conditions  as  eye-strain 
or  any  of  the  other  similar  factors  which  are  much  better  understood 
and  in  consequence  more  often  recognized  in  diagnosis.  The  jaws 
teeth,  and  other  structures  or  tissues  connected  therewith,  as  well  as 
the  contents  of  the  mouth  and  its  use,  including  hygienic  care  and 
habits  which  concern  conscious  or  unconscious  use,  are  inevitably 
matters  of  importance  in  considering  causative  factors  and  bear  an 


31G 


NERVOUS  SYSTEM  AND  THE  BUCCAL  REGION 


important  relation  to  all  divisions  of  the  foregoing  etiological  classifi- 
cation. To  say  that  these  oral  influences  are  the  most  important 
causes  would  be  rediculous  in  the  face  of  broader  knowledge  of  contrib- 
uting affections.  It  has  been,  however,  a  matter  of  frequent  occurrence 
in  the  author's  clinical  experience  that  the  correction,  treatment,  and 
care  of  the  teeth  and  mouth  for  relief  of  patients  sufi'ering  from  neu- 
rasthenia have  been  efficient  in  setting  them  on  the  road  to  recovery. 
The  results  have  been  so  satisfactory  in  helping  build  up  resistance 
against  other  pathogenic  influences  that  in  this  light  the  subject  war- 
rants the  fullest  possible  attention  under  every  circumstance. 

ANGIONEUROTIC  EDEMA. 

Angioneurotic  edema  is  a  transient  edematous  swelling  affecting 
limited  portions  of  the  surface  of  the  body. 


Fig.   159. — Condition,  in  1889,  before  enlargement  of  head  and  neck  began.     (Starr.) 


Etiology.- — ^The  cause  is  not  fully  understood.  Exposiu-e  to  cold 
seems  to  have  an  effective  immediate  influence.  Osier  recognizes  an 
hereditary  influence. 

Pathology.- — The  pathology  is  not  known. 

Symptoms. — The  s^Tiiptoms  may  affect  any  part  of  the  body,  but 
usually  appear  in  the  face  and  extremities.  There  is  swelling,  which 
may  come  and  go  quickly  or  continue  for  several  days.  Color  may 
vary  from  red  to  whitish  yellow  or  pale.  There  is  stiffness  and  numb- 
ness of  the  part. 

Treatment. — The  treatment  is  not  well  understood,  but  massage  and 
strychnin  are  recommended.  IMost  of  the  cases  reported  have  been 
those  in  which  the  sNTuptoms  were  quite  marked,  but  a  slight  transient 
edema  of  the  face  quite  unaccompanied  by  any  inflammatory  symp- 


PROGRESSIVE  LIPODYSTROPHY  317 

toms  is  frequently  noticed  in  patients  suffering  from  tic  douloureux  and 
other  ati'ections  due  to  irritation  of  the  trigeminal  nerve.  Although 
no  claim  is  made  that  these  are  identical  with  angioneurotic  edema, 
yet  in  the  absence  of  full  etiological  and  pathological  knowledge  there 
is  at  least  sufficient  similarity  to  warrant  careful  search  of  the  teeth 
and  mouth  for  possible  chronic  irritations  of  dental  pulps,  malposed 
impacted  teeth,  and  other  similar  factors  that  might  be  aggravat- 
ing influences.  The  immediate  correction  of  any  such  condition  is 
certainlv  indicated. 


Fig.  160. — Condition,  in  1894,  showing  uniform  enlargement  of  the  head.     (Starr.) 

TROPHIC  CHANGES. 

Trophic  changes  as  evidenced  by  atrophy  due  to  nervous  causes  is 
well  understood.  Hypertrophy  that  can  only  be  satisfactorily  accounted 
for  a  neurosis  occurs  occasionally.  Starr  accounts  for  the  marked 
increase  in  the  size  of  the  head  and  face  shown  in  Figs.  159  and  160 
as  due  to  one  of  the  trophic  neuroses.  These  are  of  interest  to  our 
subject  because  of  the  region  affected.  There  may  also  be  alterations 
affecting  the  hair,  face,  and  lips  of  similar  origin. 

PROGRESSIVE  LIPODYSTROPHY. 

Progressive  lipodystrophy,  a  condition  in  which  there  is  progressive 
disappearance  of  adipose  tissue  of  the  face,  upper  chest,  and  arms. 
There  are  no  symptoms  except  loss  of  subcutaneous  fat  of  the  affected 
parts,  with  increase  of  adipose  tissue  in  the  lower  parts  of  the  body. 
The  condition  is  very  rare,  approximately  16  cases  on  record.  Enlarge- 
ment of  the  thyroid  indicates  excessive  thyroid  functioning.  The 
cause  of  this  affection  is  not  definitely  known. 


CHAPTER    VI. 
DISEASES  OF  BONE. 

Among  the  elements  pertaining  to  processes  of  bone  development, 
consideration  of  which  belongs  more  properly  to  the  text-books  on 
Histology  and  Embryology,  there  are  some  which  have  such  an  impor- 
tant bearing  upon  morbid  processes  affecting  bones  of  the  face  and 
jaws  in  common  with  other  osseous  structures  that  they  deserve  brief 
consideration. 

Osteogenesis. — ^In  growing  bone  while  absorption  is  taking  place  in 
the  interior  of  the  bone,  through  the  agency  of  the  osteoclasts,  additional 
bone  is  formed  by  the  osteoblasts  upon  the  external  surface  from  the 
generic  layer  of  the  periosteum.     This  is  called  osseous  apposition. 

Osseous  Resorption. — Bone  absorption  takes  place  through  the 
action  of  nucleated  masses  of  protoplasm  directly  acting  upon  the 
calcified  matrix,  to  form  small  cavities,  called  Howslip's  lacunae. 
Osteoclasts  are  the  cells  which  accomplish  this  result.  Lacunar 
absorption  is  not  only  important  in  physiological  processes,  but  is 
frequently  concerned  in  the  pathology  of  atrophic  bone  absorption. 

Atrophy  of  Bone. — Atrophy  of  bone  may  be  eccentric  when  it  pro- 
gressses  from  within  outward,  concentric  when  it  begins  immediately 
under  the  periosteum  and  progresses  inward  with  tendency  to  lessen 
the  circumference  of  the  bone. 

The  processes  by  which  bone  absorption  takes  place  are: 
■     Lacunar  Absorption. — Described  above. 

Perforating  Canal  Absorption. — This  consists  in  the  penetration 
of  new  formed  bloodvessels  through  the  lamella  which  communicate 
with  the  Haversian  canals  and  increase  the  area  of  excavation  along 
these  channels,  thus  leading  to  osteoporosis. 

Halisteresis. — This  consists  in  the  removal  of  lime  salts,  with  subse- 
quent changes  in  the  osseous  matrix.  There  is  some  question  whether 
this  is  a  true  atrophic  process,  but  is  usually  so  considered  and  may  be 

Local. — In  connection  with  some  pathological  process ;  or, 

General. — As  an  evidence  of  constitutional  conditions,  and  is  then 
called  osteomalacia. 

Osteomalacia. — Osteomalacia  is  characterized  by  absorption  of  the 
bone  salts  with  other  changes  in  the  bone  that  cause  extreme  flexibility 
and  is  probably  a  form  of  trophic  neurosis,  although  its  exact  cause 
is  not  definitely  understood.  It  is  frequently  found  in  puerperal 
women,  and  may  be  accompanied  by  distortions,  bends,  and  even 
fractures  of  bones. 
(318) 


MALFORMATIONS  OF  BONE  319 

Regeneration  of  Bone. — Regeneration  of  bone  occurs  when  fracture 
or  loss  of  bone  structure  takes  place  through  injury  or  disease.  As  a 
result  of  irritation,  proliferative  changes  take  place,  new  bloodvessels 
are  formed,  and  the  tissue  becomes  hardened  from  deposit  of  calcareous 
matter  and  cartilaginous  formation.  Gradually  bone  is  formed 
through  the  renewed  acti^'ity  of  bone-forming  processes  thus  excited. 

In  recent  years  much  discussion  has  taken  place,  and  quite  opposite 
opinions  have  been  expressed,  concerning  the  osteogenetic  activities 
of  the  periosteiun.  To  one  accustomed  to  plastic  operations,  invohing 
the  transposition  of  periosteal  structures,  it  is  not  surprising  that  one 
experimenter  will  find  that  the  periosteum  is  incapable  of  bone  forma- 
tion when  unassisted  by  other  influences,  and  another  will  report, 
quite  as  positively,  that  the  preservation  of  the  periosteum  is  important 
for  bone  regeneration  following  operative  procedures.  Undoubtedly 
the  personal  equation  is  an  important,  often  a  deciding,  influence  in 
determining  such  experimental  results.  Personally,  the  author  has 
no  doubt  of  the  osteogenetic  functions  when  the  periosteimi  is  pre- 
served intact,  and  uninjured,  in  its  natural  situation.  Evidences 
of  this  may  be  seen  on  pages  440  and  467.  The  testimony  of  successful 
bone  grafts  ma}'  also  be  adduced  to  prove  this  contension.  Quite 
naturally  it  is  the  combination  of  periosteum  with  extension  of  bone 
growth  from  fractured  or  divided  bone  ends  that  is  required,  and  such 
combination  should  be  contemplated  in  designing  surgical  procedures. 

Pressure  Atrophy. — Pressure  atrophy  occurs  from  constantly 
applied  pressure.  This  may  be  mechanical  or  due  to  tumors,  aneu- 
rysms, the  accumulation  of  fluid  in  ca^dties  surrounded  by  bone,  as  in 
the  air  sinuses  of  the  face,  abscess,  cysts,  and  similar  conditions.  It 
is  upon  this  principle  that  the  effectiveness  of  orthopedic  and  ortho- 
dontic appliances  depends. 

Surgically,  questions  of  bone  formation,  resorption,  and  regenera- 
tion are  of  great  importance  as  affecting  restoration  of  bone  when 
destroyed  by  disease  or  surgically  removed;  the  possibility  of  bone 
formation  taking  place  from  periosteum  that  has  been  left  intact  after 
the  removal  of  sequestra  of  necrosed  bone,  and  the  renewed  acti\'ity 
of  osteoblasts  in  persons  of  advanced  years,  or  who  have  passed  the 
period  of  normal  bone  growth;  in  repair  of  fractures  and  reconstruc- 
tion following  operations.  Such  questions  also  constantly  arise  in 
connection  with  bone  absorption  incident  to  the  movement  of  teeth 
in  orthodontic  treatment  and  in  operations  for  cleft-palate,  particu- 
larly as  related  to  the  results  from  mucoperiosteal  flaps. 

Malformations  of  Bone. — Etiology. — The  many  perversions  of  osse- 
ous development,  which  are  usually  evidenced  by  defective  or  per- 
verted bone  formation,  may  be  due  to  general  disease,  inherent  tendency, 
achondroplasia,  i.  e.,  defect  in  the  laying  dovm  of  primary  enchondrial 
matrix  from  which  most  of  the  bones  of  the  skeleton  are  formed,  and 
in  which  such  defects  are  later  evidenced,  arrested  development,  afec- 
tions  of  the  central  nervous  system,  traumatic  injuries,  abnormal jnuscular 


320  DISEASES  OF  BONE 

action  as  influencing  perversion  of  form,  imperfect  metabolism,  rachitis 
(rickets),  and  other  causes  which  are  more  specifically  described  in 
chapters  relating  to  deformities. 

Agenesis. — Entire  failure  of  develoj^ment  ma,y  be  restricted  to  one  bone, 
a  part  of  a  bone,  or  the  entire  skeleton,  as  in  microsomia,  nanosomia, 
the  terms  used  to  describe  dwarfs. 

Changes  in  hone  marrow  result  from  systematic  conditions  and  from 
local  disease;  usually  this  is  a  marked  feature  in  pernicious  anemia, 
acute  leukemia,  and  acute  infections. 

Osteogenesis  Imperfecta. — Congenital  insufficiency  of  the  bone- 
building  elements  results  in  a  condition  of  osseous  structure  which  is 
in  effect  much  like  osteomalacia.  Such  children  are  usually  very 
small  at  birth,  with  evidence  of  more  or  less  imperfection  of  general 
form.  The  bones  are  extremely  fragile  and  fracture  easily.  Not 
infrequently  there  is  mental  defect  also. 


RICKETS,  RACHITIS,  RACHITISMUS,  MORBUS  ANGLICUS. 

Rickets. — Rickets  is  a  constitutional  disorder  characterized  by  ab- 
normal development  of  the  bones  and  other  structures  with  lack  of 
normal  calcification. 

Etiology. — The  etiology  is  not  fully  understood.  It  is  believed  to  be 
a  disorder  of  nutrition  during  the  period  of  active  growth. 

Pathology. — Osteoporosis  results  from  lacunar  absorption.  Osteo- 
phytes are  formed  from  unusual  periosteal  activity.  There  is  abun- 
dant production  of  osteoid  matrix  penetrated  by  medullary  vessels,  but 
there  is  a  lack  of  normal  deposits  of  bone.  Ligamentous  attachments 
of  bone  are  imperfect,  there  is  deficient  muscular  development  as  well 
as  pathological  abnormalities  of  the  internal  organs,  with  catarrhal 
aftections  of  the  mucosa. 

Prognosis. — Prognosis  depends  upon  the  possibility  of  inducing 
natural  or  forced  improvement;  the  developmental  processes  before 
prognosis  of  the  disease  has  rendered  such  improvement  possible. 

Treatment.^ — Treatment  should  be  governed  by  such  measures  as 
may  tend  to  improve  nutrition  and  facilitate  normal  general  devel- 
opment. There  should  be  a  nourishing  diet,  which  should  include 
fats  and  nourishing  oils  in  such  quantities  as  may  be  properly  assimi- 
lated. Cod-liver  oil  and  phosphorus  may  be  beneficial,  baths,  massage, 
open-air  exercise,  and  generally  healthful  condition  must  be  insured, 
and  supplemented  by  proper  support  and  correction  of  osseous  deform- 
ities. In  these  cases  there  is  usually  more  or  less  marked  abnormality 
in  development  of  the  teeth  and  jaws.  Proper  regulation  of  these 
conditions  ofi'ers  favorable  opportunity  for  rendering  assistance  to  these 
patients,  both  directly  and  indirectly. 

Hypertrophy  of  Bone. — Hypertrophy  of  bone  may  be  local  or 
general. 


ACROMEGALY  321 

Local  Hypertrophy. — Etiologij. — Increased  or  unusual  development  of 
muscles  sometimes  causes  ridges  and  thickening  of  the  bone  surface  to 
which  the  muscles  are  attached.  Chronic  irritation  of  the  periosteum 
may  also  cause  increase  of  bone  structure. 

Symptovis.— The  symptoms  are  ridges  or  excrescences  upon  bone 
surfaces,  abnormal  thickness  or  giant  growth  which  may  affect  certain 
bones  or  part  of  the  skeleton.  In  children  this  is  usually  noted  in  the 
upper  extremities. 

General  Hypertrophy. — Gigantism,  general  hypertrophy,  or  complete 
giant  growth  is  usually  first  noted  about  the  age  of  puberty.  The 
bones  become  large,  thickened,  and  irregular,  and  the  individual 
sometimes  attains  an  enormous  size. 

Acromegaly. — This  disease  is  characterized  by  giant  growth  which 
affects  both  flat  and  long  bones,  but  is  most  frequently  noticeable  in 
the  face,  particularly  the  lower  jaws  and  nose,  the  hands  and  feet, 
forearms  and  legs.  It  is  accompanied  by  more  or  less  hyperplasia 
of  the  soft  tissues  in  the  affected  regions. 

Etiology.^ — That  there  is  some  etiological  relationship  between  gigan- 
tism and  acromegaly  as  well  as  leontiasis  ossea  and  hemihypertrophy 
of  the  face  is  generally  conceded,  although  not  fully  understood.  The 
most  commonly  accepted  theory  at  the  present  time  is  that  it  results 
from  some  pathological  condition  of  the  hypophysis  cerebri  and 
enlargement  of  the  sella  turcica  found  in  the  skeletons  of  giants  has 
been  accepted  as  evidence  of  the  enlargement  of  the  pituitary  body. 
Gushing,  Sajous  and  others  have  gathered  evidence  to  prove  that  there 
is  a  direct  relationship  between  pituitary  disease  and  bone  hyper- 
trophies. 

Symptoms. — The  lower  jaw  increases  in  length  and  thickness, 
becomes  swollen,  prognathous,  and  may  project  much  beyond  the 
upper.  This  together  with  growth  in  the  length  and  thickness  of 
condyles  sometimes  renders  occlusion  of  the  teeth  impossible.  The 
nose  becomes  thick  and  broad,  the  lips  thick  and  protruding,  the  facial 
sinuses  much  enlarged,  with  more  or  less  bulging  in  this  region.  The 
hands  and  feet  become  enormously  large  and  thick.  Similar  changes 
may  take  place  in  the  pelvic  bones,  the  sternum,  ribs,  and  in  the  spine, 
which  with  a  drooping  forward  of  the  head  and  the  prognathous  lower 
jaw  give  an  ape-like  deformity  (Fig.  161). 

Prognosis. — As  there  is  no  exact  knowledge  of  the  cause,  and  treat- 
ment is  uncertain,  the  prognosis  must  necessarily  be  grave.  The 
progress  of  this  disease,  however,  is  often  very  slow  and  does  not 
directly  shorten  the  period  of  life. 

Treatment. — Aside  from  such  operative  procedure  as  in  rare  in- 
stances may  be  required  to  overcome  the  inconvenience  and  ill  effect 
of  the  deformity,  especially  to  make  possible  the  use  of  the  jaws  in 
mastication,  the  only  hopeful  treatment  seems  to  lie  in  the  adminis- 
tration of  pituitary  extract,  with  rest,  change  of  occupation,  and  such 
supplementary  measures  as  may  tend  to  restore  general  nervous  balance. 
21 


322 


DISEASES  OF  BONE 


Gushing  has  suggested  and  reported  good  results  from  operations 
for  removal  of  pathological  processes  which  may  effect  the  gland. 

One  case  of  a  man  past  middle  life  was  referred  to  the  author  for 
operation  to  make  closure  of  the  jaws  possible.  All  the  topical  symp- 
toms of  this  affection  were  present  in  very  marked  degree,  but  further 
progress  of  the  unwelcome  growth  had  already  been  checked,  presum- 


FiG.   161. — -Acromegaly.      (Park.) 


ably  by  long-continued  treatment  with  pituitary  extract,  and  the 
mechanical  difficulty  of  occlusion  had  been  so  well  overcome  by 
ingenious  dental  work  performed  by  Dr.  Robin  Adair,  of  Atlanta, 
Georgia,  that  it  seemed  unnecessary  to  incur  the  risk  and  uncertainty 
of  operation  upon  the  jaws.     (See  Fig.  162.) 

Hemihypertrophy  of  the  Face. — This  condition,  in  which  the  bones 
of  the  face  become  enlarged  upon  one  side,  is  presumably  closely  allied 
to  acromegaly,  although  its  true  character  is  not  fully  understood. 

Leontiasis  Ossea. — This  form  of  bony  growth  affects  with  more  or 
less  symmetrical  enlargement  the  facial  bones  upon  both  sides,  particu- 


LEONTIASIS  OSSEA 


323 


larly  the  upper  part  of  the  face,  and  has  received  its  name  on  account 
of  the  Uon-Hke  appearance  of  the  countenance. 

Etiology. — Etiolo<2:ically  there  seems  to  be  every  reason  to  beheve 
tliat  all  of  these  afi'ections  are  closely  allied,  but  definite  knowledge  is 
lacking. 


Fig.  162. — This  ■patient  had  formerly  been  under  the  care  of  Dr.  Gushing  at  Baltimore, 
and  it  is  from  his  work  on  the  pituitary  body  that  these  pictures^were  taken.  Patient 
before  the  onset  of  the  malady  (aged  eighteen) ;  at  the  time  of^the  onset  (aged  twenty- 
six)  ;  after  its  full  development  (aged  forty) . 

Symptoms. — In  the  course  of  development  of  hypertrophied  bone, 
it  may  restrict  the  size  of  the  orbits,  the  nasal  passages,  or  foramina, 
and  by  compression  of  enclosed  structures,  especially  when  nerve 
trunks  are  involved,  give  rise  to  painful  or  other  symptoms  of  nervous 
disturbance  (Fig.  163). 


Fig.  163. — Leontiasis.     Skull  of  a  Chinese  woman.     (.U.  S.  A.  Museimi,  No.  10,620.) 


Treatment. — Surgical  treatment  is  practically  unavailing,  because 
removal  of  portions  of  the  h\q3ertrophied  bone  only  gives  temporary 
relief  and  the  deformity  quickly  returns. 


324  DISEASES  OF  BONE 

Ostitis  Deformans. — Ostitis  deformans  is  a  disease  of  middle  life 
or  later,  manifested  by  thickening  of  the  sknll  and  long  bones,  marked 
softening  and  loss  of  resistance  to  pressure. 

Etiology. — Its  etiological  character  is  unkno^^■n.  There  is  a  differ- 
ence of  opinion  as  to  whether  it  is  a  result  of  an  inflammatory  cause, 
trophic  disturbance,  or  sjq^hilis. 

Pathology. — The  compact  bone  becomes  absorbed  with  confluence 
of  the  Haversian  canals,  and  there  is  new  formation  of  uncalcified 
osseous  tissue  with  accompanying  alteration  in  form. 

Symptoms.— The  symptoms  include  broadening  of  the  cranium, 
curvatures  of  the  long  bones,  pain  and  discomfort  in  the  affected 
region. 

Treatment. — Until  its  character  is  better  understood  its  treatment 
must  necessarily  be  only  for  the  relief  of  such  general  pathological 
states  as  might  be  recognized  as  interfering  with  bone  nutrition,  and 
good  hygienic  care  is,  of  course,  always  indicated. 

The  removal  of  all  focal  infection  in  such  cases  should  not  be  over- 
looked. 

DISEASES  OF  THE  PERIOSTEUM. 

Hemorrhage  under  the  Periosteum. —  Etiology. — This  condition  may 
be  caused  by  scurvy  and  other  blood  diseases,  trauma,  or  infectious 
diseases. 

Pathology. — The  formation  of  a  blood  clot  under  the  periosteum 
destroys  its  attachment  from  the  bone  over  a  more  or  less  extensive 
area.  If  infected,  there  may  be  suppuration,  necrosis,  and  the  results 
which  follow  in  sequence  from  these  conditions. 

Prognosis  and  Treatment. — When  absorption  in  natural  course  is 
sufficient  to  remove  the  blood  the  symptoms  subside  without  treatment, 
but  if  this  does  not  occur  spontaneously  then  treatment  is  required 
to  be  directed  toward  overcoming  the  disease  acting  as  an  underlying 
cause,  or  to  cure  pathological  results  as  described  in  consideration  of 
periostitis. 

Periostitis. — ^Inflammation  of  the  periosteum  may  be  acute  or 
chronic.  Its  foims  are  simple  or  non-infective,  siippurative,  and  ossi- 
fying, or  osteop)enostitis. 

Acute  Simple  Periostitis. — Etiology. — This  form  is  due  to  trifling  or 
traumatic  injuries  to  the  periosteum  without  infection. 

Pathology. — The  periosteum  becomes  swollen  and  may  be  separated 
from  the  underhing  bone  by  subperiosteal  hemorrhage.  This  is 
quickly  followed  by  absorption  of  the  blood,  proliferation  of  connective 
tissue,  and  more  or  less  leukocytic  infiltration.  Through  the  activity 
of  the  phagocj'tes  the  blood  is  removed,  the  cellular  products  of  the 
inflammatory  condition  may  result  in  the  formation  of  cicatricial 
tissue  which  may  become  calcified  or  form  bone  by  the  assistance  of 
the  osteoblasts. 


DISEASES  OF  THE  PERIOSTEUM  325 

SymiHoms. — Pain,  tenderness  to  pressure,  and  sometimes  hemor- 
rhage under  the  periosteum,  which  causes  more  or  less  separation  from 
the  bone,  are  prominent  symptoms. 

Prognosis. — The  prognosis  is  good,  except  when  infection  takes 
place. 

Treatment. — Usually  little  assistance  is  required  to  hasten  recovery. 
Hot  fomentations  and  occasionally,  in  the  more  troublesome  cases 
with  extensive  hemorrhage  under  the  periosteum,  incision  through  the 
overlying  tissues  down  to  the  bone  surface,  to  be  followed  by  suitable 
antiseptic  dressings. 

Purulent  Periostitis. — Periostitis  due  to  infection  by  microorganisms 
may  be  circumscribed,  confined  to  a  small  area,  or  diffuse,  when  the 
suppurative  process  tends  to  spread  over  the  bone  surface  and  separate 
the  periosteal  attachments  over  a  more  or  less  considerable  area. 

Etiology.— Suppurative  periostitis  is  associated  with  both  ostitis  and 
osteomyelitis,  being  sometimes  a  cause  and  sometimes  a  result  of  these 
diseases.  Its  etiological  factors  are  therefore  identical  with  those 
enumerated  in  description  of  these  affections  of  bone  (see  p.  326). 

Pathology. — There  is  more  or  less  marked  swelling  and  cellular 
infiltration  w  ith  pus  formation  which  tends  to  separate  the  periosteum 
and  bone.  If  sufficient  to  interfere  with  circulation  and  nourishment 
over  an  extended  area  of  bone  surface  superficial  necrosis  with  exfolia- 
tion results. 

Treatment. — ^The  treatment  of  purulent  periostitis  requires  removal 
or  treatment  of  the  cause,  relief  of  the  pus  by  incision  down  to  the  bone 
under  antiseptic  precaution,  and  cleansing  of  the  wound,  preferably 
with  tincture  of  iodin.  The  application  of  hot  gauze  wrung  out  in 
boric  acid  solution,  1  to  1000  bichloride  of  mercury  or  other  suitable 
antiseptic,  which  may  be  required  to  check  if  possible  both  the  danger 
of  more  general  infection  and  local  destruction  of  the  underlying 
bone. 

Osteoperiostitis. — Osteoperiostitis  may  result  from  long-continued, 
not  too  severe  chronic  irritation  and  from  constitutional  diseases, 
notably  syphilis. 

Pathology. — A  proliferation  of  the  osteogenetic  layer  of  the  perios- 
feum  takes  place,  the  partial  ossification,  and  finally  complete  bone 
formation  with  attachment  to  the  underlying  bone,  results  in  the  form 
of  excrescences,  exostoses,  or  osteophytes. 

Treatment. — Treatment  consists  in  removal  of  the  cause  and  when 
required  removal  of  the  superfluous  bone.  These  growths  are  frequently 
noticeable  in  the  maxillse,  sometimes  along  the  central  division  of  the 
palate.  Occasionally  there  are  enlargements  of  the  buccal  side  and 
posterior  to  the  tuberosities  and  at  other  points  in  the  neighborhood 
of  the  roots  of  teeth.  Usually  they  are  unattended  by  disturbing 
symptoms.  Occasionally  the  bone  growth  interferes  with  some  other 
parts,  and  its  removal  is  required. 


326  DISEASES  OF  BONE 


INFLAMMATION  OF  BONE. 

Inflammation  of  bone  is  recognized  in  two  principal  forms.  These 
are  osteitis  or  ostitis,  inflammation  of  the  compact  portion  of  the  bone, 
and  osteomyelitis,  inflammation  originating  in  or  extending  to  the 
medullary  structures. 

Clinically  it  is  practically  impossible  to  differentiate  between  these 
two  forms  of  bone  inflammation  because  almost  invariably  one  leads 
to  the  other. 

Osteomyelitis. — Osteomyelitis  is  an  infective  disease  involving  at 
first  the  bone  marrow  and  central  or  cellular  parts  of  the  bone. 

Etiology .^ — Its  causes  are  pyogenic  microorganisms  following  trau- 
matic injury,  suppurative  forms  of  periostitis,  infection  through  the 
circulation,  infective  diseases,  dento-alveolar  abscess,  fracture  and 
toxic  effects  from  mineral  or  other  poisons.  Quite  frequently  it  has 
been  found  to  be  the  result  of  infection  from  the  pneumococcus, 
Bacillus  typhosus,  Bacillus  coli  communis,  tubercle  bacilli,  and  other 
microorganisms. 

Pathology. — Cellular  infiltration  and  proliferation  accompany 
changes  in  the  bone  marrow.  Vascular  distention  is  associated  with 
thrombosis,  which  is  followed  by  coagulation  necrosis,  liquefaction  of 
intercellular  substance  and  the  development  of  purulent  foci.  Coal- 
escence of  these  tiny  abscesses  leads  to  rapid  destruction  of  bone. 
Dead  bone  is  thrown  off  in  the  form  of  a  sequestrum,  and  suppurative 
periostitis  conveys  the  infection  to  the  overlying  tissues  with  resulting 
inflammation  and  the  formation  of  a  sinus  for  the  discharge  of  pus. 

Symptoms  and  Treatment. — See  Necrosis. 


NECROSIS  OF  THE  JAWS. 

Necrosis  and  caries  of  bone  are  sequelae  of  bone  inflammation,  and 
since  it  is  these  conditions  of  the  maxillary  bones  that  most  frequently 
require  treatment,  the  acute,  subacute,  and  chronic  forms  of  both, 
ostitis  and  osteomyelitis,  as  well  as  the  sjmiptoms  and  treatment  of 
these  associated  conditions,  will  be  considered  together  in  their  relation 
to  necrosis  for  purposes  of  simplification  and  clinical  directness. 

Necrosis  and  Caries. — Necrosis  is  death  of  bone  en  masse.  Tech- 
nically any  dead  tissue  is  necrotic,  but  the  term  necrosis  is  usually 
applied  to  distinguish  from  a  slough,  gangrene,  or  death  en  masse 
of  soft  tissue.  Caries  is  molecular  destruction  of  bone.  A  similar 
condition  affecting  the  soft  tissues  is  called  an  ulcer. 

Etiology. — Acute  or  chronic  diseases  of  the  periosteum,  bone  marrow, 
and  adjacent  bone,  and  interference  with  blood  supply  by  separation 
from  the  underlying  bone  in  purulent  periostitis  are  the  direct  causes 
of  necrosis. 


NECROSIS  OF  THE  JAWS  327 

The  factors  to  which  these  conditions  are  due  have  already  been 
described  as  injury,  infection  by  pathogenic  microorganisms,  including 
staphylococci  and  other  bacterial  forms  recognized  as  representative 
of  general  disease  and  the  toxic  effects  of  certain  mineral  and  other 
poisons,  which  are  also  capable  of  producing  the  practically  inseparable 
chain  of  conditions  associated  with  bone  inflammation.  Some  of  these 
causes  require  individual  recognition  and  special  treatment  in  order 
to  secure  successful  results  from  local  treatment  of  the  diseased 
bone. 

The  classification  of  etiological  factors  on  page  328  is  presented 
as  arranged  for  clinical  convenience  and  assistance. 

There  are  some  peculiarities  of  necrosis  of  jaws  the  importance  of 
which  has  been  impressed  upon  the  author  by  a  long  series  of  cases  in 
which  very  disastrous  results  might  have  been  averted  by  early  recog- 
nition of  the  cause.  In  some  of  these,  as  will  be  noted,  the  process 
of  bone  destruction  continued  for  fifteen  years  and  more,  with  widely 
distributed  ill  results  through  constant  absorption  of  toxic  products 
by  the  general  system.  The  following  cases  are  topical  forms  of 
necrosis  of  the  jaws,  therefore  each  has  an  important  significance. 

Case  I. — This  was  a  child,  aged  five  years,  with  history  of  trouble 
with  pain,  which  began  many  months  before  coming  under  the  author's 
care.  There  were  swelling  and  soreness  of  the  mouth  in  the  region 
of  the  premolar  teeth,  high  temperature,  malaise,  and  a  slight  eruption 
upon  the  skin.  Her  physician  diagnosticated  t^-phoid  fever;  later 
the  disease  was  termed  some  other  form  of  fever.  Upon  examination 
it  was  found  that  large  sequestra  of  bone  representing  the  major  por- 
tion of  both  upper  and  lower  jaws  were  in  a  state  of  exfohation,  and  so 
completely  had  Nature  performed  her  office  in  this  respect  that  upon 
removal  of  the  dead  pieces  of  bone  newly  granulated  surfaces  beneath 
them  were  found  to  be  perfectly  healthy  and  the  child  discharged  from 
the  hospital  as  practically  cured  the  day  following  the  operation. 

Case  II. — This  was  the  case  of  a  young  boy,  Harry  D.,  aged  seven 
years.  Trouble  began  with  toothache,  which  lasted  for  six  months. 
After  extraction  of  tooth,  swelling  began  in  the  face.  The  s^Tiiptoms 
were  fistula  with  pus  discharge  at  extreme  angle  just  below  right  eye. 
Depression  was  marked  in  that  region  and  the  lower  eyelid  was  everted. 
There  had  been  one  or  two  operations  performed,  and  his  surgeon 
finally  advised  the  parents  to  wait  until  all  of  the  dead  bone  might  be 
forced  out  through  the  fistula  just  at  the  outer  angle  of  the  eye.  At 
this  point  several  pieces  had  been  removed.  It  was  found  that  almost 
the  entire  upper  maxilla  upon  the  aft'ected  side  was  necrosed.  By 
carefully  removing  each  loosened  piece  of  bone  without  disturbing 
underlying  structures  it  was  possible  to  leave  the  molar  teeth  in  course 
of  eruption  partly  embedded  in  healthful  bone  structure.  Later 
development  proved  that  new  bone  was  formed  about  these  teeth  and 
in  that  wav  serious  deformitv  was  avoided. 


328 


DISEASES  OF  BONE 


Diseases  of  the 
teeth  and  al- 
veolar struc- 
tures 


Dento-alveolar 
abscess 


Devitalized  or  infected,  or 
Gangrenous  tooth  pulps. 
Imperfectly  filled  roots  of  teeth. 
Fractured  roots  of  teeth. 

Implantation,  transplantation,   and  replantation 
of  roots  of  teeth. 


Chronic  pericementitis. 

Pyorrhea  alveolaris. 

Pericemental  abscess. 

Ulcerative  stomatitis. 

Gangrenous  stomatitis. 

Gangrenous  conditions  of  the  buccal  tissues. 


Traumatism 


Injury  to  the  periosteum  with  subsequent  infection , 
Compound  fractures  of  the  jaw  or  of  teeth,  or 

dislocation  of  roots  of  teeth. 
External  blows,  or  force  causing  the  jaws  to  strike 

forcibly  together,  causing  subsequent  death  and 

infection  of  and  from  tooth  pulps. 


Foreign  bodies  in  the  tissues. 

Extension  of  nasal  disease. 

Empyema  of  the  maxillary  sinus. 

Middle-ear  disease,  furuncle  or  other  inflammatory  affections   of    the   skin    and    soft 

issues  of  the  face. 
Surgical  operations  upon  the  maxillary  bones. 


Infectious 
diseases 


Blood  disorders 


Exanthemata  or  eruptive  fevers 

Influenza  (la  grippe). 
Tuberculosis. 
Syphilis. 
Actinomycosis. 
Glanders. 
_  Leprosy. 

Predisposing  conditions 

Leukemia. 
Pernicious  anemia. 
Scurvy. 
Septicemia. 
Pyemia. 


Inorganic  poisons 


I  Typhoid  fever. 
Scarlet  fever. 
Measles. 
Smallpox. 


Toxic  agents 


Organic  poisons 


Anemia. 
Chlorosis. 


Mercury. 

Arsenic. 

Phosphorus. 

Lead. 

Corrosive  and  escharotic. 

Acids  and  alkalies. 

'  Vegetable  poisons  in  the  form  of 
drugs  may  lead  to  necrosis  by 
their  direct  destructive  action 
upon  tissue,  or  secondarily  by 
causing  depleted  conditions  to 
the  general  system,  or  induc- 
ing diseases  of  special  organs 
which  may  predispose  to  bone 
diseases,  as  may  also  animal 
poisons,  such  as  bites  of  ven- 
omous reptiles,  stings  of  in- 
sects, etc. 


NECROSIS  OF  THE  JAWS  '  329 

Case  III. — Sam.  F.  K.,  aged  twelve  years.  Necrosis.  Extreme 
pain  in  lower  jaw  for  about  ten  days.  November,  1905,  temperature, 
102°,  followed  by  swelling  in  right  side.  Was  opened  through  skin 
surface  beloM'  bicuspid  region.  Later  an  opening  for  pus  was  made 
under  chin  on  left  side.  Some  sequestra  of  necrosed  bone  were  re- 
moved from  time  to  time.  Present  time  (March  0,  1906)  opening 
from  socket  of  the  L.  I.  C.  I.  and  along  jaw  from  lateral  to  molar  on  left 
side,  one  erupting  bicuspid  on  left  side.  Fistula  under  chin  on  left 
side.  Thickened  and  swollen  tissue  from  right  inferior  to  left  inferior 
second  molar  region. 

There  was  necrosis  of  the  inferior  maxilla  from  the  angle  to  the 
symphysis.  Several  previous  operations  had  given  no  result  beyond 
temporarily  checking  the  progress  of  the  disease.  The  fact  that  several 
teeth  had  become  devitalized  before  their  pulps  were  gangrenous  and 
were  constant  sources  of  reinfection  had  been  overlooked.  These  were 
removed  with'the  dead  bone,  but  at  several  points  in  the  jaw  the  enamel 
caps  of  developing  but  still  deeply  embedded  permanent  teeth  were 
noted,  and  these  with  much  care  were  preserved.  The  result  in  both 
these  cases  made  possible  continued  development  and  growth  in  the 
affected  region.  This  could  never  have  taken  place  if  all  of  the  teeth 
had  been  destroyed,  and  in  natural  course  of  development  one  side  of 
the  face  would  have  been  left  deeply  indented  and  much  deformed. 

The  great  prevalence  of  these  extensive  necroses  in  growing  children 
is  undoubtedly  because  the  jaws  are  so  filled  with  the  crowns  of  devel- 
oping teeth  that  circulation  and  bone  nourishment  is  much  impaired. 
Therefore  bone  infections  from  any  cause  easily  result  in  extensive 
destruction. 

Fig.  164  represents  a  women  who  gives  a  striking  example  of  an 
acute,  diffuse,  suppurative  periostitis  and  the  involvement  of  adjacent 
tissue  from  an  original  infection  by  putrescent  roots  in  the  lower  jaw. 
Extensive  abscess  followed,  and  on  account  of  illness  during  pregnancy 
the  patient  was  confined  to  her  bed  for  several  months.  The  prone 
position  favored  the  spreading  out  of  pus  under  the  periosteum. 
Large  numbers  of  scars  from  fistulse  may  be  noted  as  low  down  as  the 
clavicle.  The  whole  submaxillary  area  and  the  neck  from  jaws  to 
clavicle  at  times  were  filled  with  pus  so  that  the  skin  hung  down  like  a 
pouch.  This  large  abscess  was  continuous  with  one  discharging 
through  the  center  of  the  cheek  and  again  at  the  outer  angle  of  the  eye. 
Irrigation  through  any  one  of  the  openings  forced  fluid  through  all  the 
others.  Prompt  recovery  followed  removal  of  dead  bone  and  thorough 
drainage. 

Fig.  165  illustrates  a  type  of  necrosis  quite  frequently  met  with 
when  caries  of  bone  extends  from  the  maxillary  region  until  it  includes 
either  the  maxillary  sinus  or  the  nose,  or  both,  and  the  hard  palate. 
In  syphilitic  cases  this  is  quite  a  common  form  of  necrosis,  and  in  those 
cases  the  disease  usually  extends  from  the  nose  down  through  the  hard 
palate.     One  young  man,  Mr.  Harry  D.,  aged  twenty-five  years,  had 


330 


DISEASES  OF  BONE 


Fig.  164. — Woman  with  pus  discharging  from  fistulje  in  neck,  cheek,  and  at  the  outer 
portion  of  lower  eyelid  from  an  original  abscess  of  a  lower  molar  tooth. 


Fig.  165. — A  typical  case  of  necrosis,  affecting  bony  walls  of  the  maxillary  sinus,  the 
nose  and  the  mouth  after  removal  of  necrosed  bone. 


NECROSIS  OF  THE  JAWS  331 

had  an  accidental  blow  at  the  age  of  twelve.  Discharge  from  region 
of  incisors  had  been  present  ever  since.  Necrosis  had  gradually 
destro.yed  and  included  the  anterior  portion  of  the  superior  maxillary 
bones  including  the  palatal  processes,  so  that  there  was  a  large  opening 
into  the  hard  ])alate.  He  had  suffered  from  the  toxic  effect  of  con- 
tinuous suppuration  in  this  region  until  the  condition  of  his  palate  was 
very  much  disordered.  He  had  been  affected  with  what  he  believed 
to  be  rheumatism.  Opening  through  the  hard  palate  necrosis  in  the 
region  of  the  lateral  incisor  was  found.  On  account  of  the  color, 
it  was  determined  that  this  tooth  had  become  devitalized  years  before 
as  a  result  of  traumatism.  Upon  opening  it  was  found  filled  with  pus. 
A  history  of  trouble  with  the  upper  jaw  following  traumatic  injury 
fifteen  years  before  was  given.  He  ^'as  sent  to  the  author  to  have  an 
opening  in  his  hard  palate  closed.  Examination  disclosed  the  fact  that 
bone  destruction  was  yet  in  progress.  Repeated  operations  had  failed 
to  do  any  good.  His  disorder  had  been  diagnosticated  as  long-con- 
tinued chronic  rheumatism,  but  later  it  proved  to  be  the  result  of  long- 
continued  septic  intoxication.  The  opening  had  extended  through  the 
hard  palate  into  the  nose,  as  described  b}^  the  patient  through  caving  in 
of  the  bone.  It  was  plain  at  a  glance  that  an  upper  tooth  upon  the 
affected  side  was  discolored,  and  it  should  have  been  understood  by 
those  who  saw  the  case  long  years  before  that  as  a  result  of  the  trau- 
matism at  the  time  of  injury  the  pulp  in  that  tooth  became  devitalized 
and  subsequently  infected. 

Over  and  over  again  in  the  author's  practice  such  teeth  have  been 
found  to  be  the  cause  of  much  long-continued  necrosis;  because  of  the 
fact  that  the  crowns  of  the  teeth  were  not  noticeably  decayed  and  there 
was  no  outward  e\'idence  of  the  tooth  being  affected  except  slight  dis- 
coloration, this  cause  had  been  overlooked.  It  should  be  a  matter 
of  routine  procedure  to  examine  every  tooth  upon  the  affected  side 
in  every  such  case,  not  only  by  throwing  reflected  light  from  an  elec- 
tric mouth  lamp  through,  the  teeth,  but  by  tests  of  heat  and  cold. 
Whenever  there  is  the  slightest  doubt  of  the  vitality  of  the  pulp  of  any 
tooth  it  should  be  opened  and  its  exact  status  definitely  determined. 
The  loss  of  an  occasional  tooth  pulp  which  it  might  become  necessary 
to  remove  in  the  course  of  such  treatment  should  not  be  considered  for 
a  moment  in  comparison  with  the  serious  results  that  follow  the  over- 
looking of  such  a  tooth  or  teeth  where  extensive  necrosis  is  already 
in  progress  or  when  operation  of  any  kind  is  contemplated  in  that 
region  of  the  jaws. 

Tuberculosis  of  Bone. — ^Tuberculosis  of  bone  is  manifested  in  the 
form  of  an  acute  tuberculous  osteomyelitis  with  miliary  tubercles  dis- 
seminated through  the  bone  marrow  or  by  chronic  tuberculosis  of  the 
bone,  which  may  begin  in  the  periosteum,  bone  marrow,  synarthrosis, 
epiphyseal  disk,  or  epiphysis. 

Etiology. — The  bacilli  most  frequently  reach  the  bone  through  the 
circulation,  although  infection  may  occur  from  contiguous  structures 
or  through  the  lymphatics. 


332  DISEASES  OF  BONE 

Pathology. — Proliferation  of  fixed  connective-tissue  cells  and  leuko- 
cytic infection  leads  to  the  formation  of  granulation  tissue.  Absorp- 
tion of  the  adjacent  bone  progresses  in  advance  of  the  tuberculous 
formation.  As  a  result  of  the  specific  poison  of  the  tubercle  bacillus, 
changes  occur  in  the  newly  formed  vessels  which  are  followed  by 
caseation  at  or  near  the  center  of  the  diseased  area.  By  extension 
this  may  lead  to  perforation  of  the  periosteum  and  cause  'periosteal 
tuberculosis,  and  lead  to  formation  of  what  is  known  as  cold  abscess. 
When  the  hip  is  affected,  the  disease  is  known  as  coxalgia;  when  the 
knee,  as  tvhite  swelling;  and  when  the  vertebra,  as  Potfs  disease. 
Large  masses  of  necrotic  bone  may  form  and  by  continued  bone 
destruction  may  affect  articular  surfaces  or  quickly  destroy  the  useful- 
ness of  joints. 

Symptoms,  Treatment,  and  Prognosis. — See  Tuberculosis,  pp.  94  to 
107. 

Syphilis  of  Bone. — Syphilis  of  bone  is  responsible  for  many  widely 
different  lesions.  In  congenital  syphilis  the  bones  at  birth  sometimes 
show  characteristic  alterations.     Calcification  is  irregular. 

Syphilitic  osteochondritis  due  to  proliferated  changes  in  the  peri- 
chondrium and  similar  abnormalities  of  the  periosteum  cause  more  or 
less  marked  thickening  and  irregularity  of  form.  In  acquired  cases  bone 
lesions  occur  during  the  tertiary  stage.  During  the  secondary  stage 
gummata  in  the  periosteum  or  disturbance  in  the  bone  marrow,  with 
degenerative  and  necrotic  processes,  may  involve  the  overlying  tissues 
and  induce  pyogenic  infection.  Bone  destruction  may  continue  until 
large  areas  have  become  necrotic,  or  through  chronic  diseases  of  the 
periosteum  there  may  be  osseous  overgrowth  resulting  in  osteophytic 
enlargement,  irregularities  of  the  surface,  osteosclerosis,  and  similar 
structural  alterations.  The  mouth  and  jaws,  which  offer  unusual 
opportunities  for  infection  through  nasal,  dental,  pharyngeal,  aural,  and 
oral  diseases,  are  frequently  affected  by  manifestations  of  this  disease 
in  the  form  of  necrosis.  A  very  common  symptom  is  an  opening 
thi"ough  the  hard  palate,  which  usually  occurs  from  the  extension  of 
disease  from  the  nose  with  destruction  of  the  nasal  cartilage  vomer  and 
the  bony  palate.     (See  Syphilis,  p.  120.) 

Actinomycosis  of  Bone. — ^This  disease  most  commonly  affects  the 
jaws,  but  the  vertebrae,  ribs,  and  sternum  may  also  be  attacked. 

Etiology.— It  is  due  to  infection  by  the  ray  fungus  and  favored  by 
abrasions  in  the  surface  of  the  mucous  membrane  of  the  mouth,  tooth 
sockets  after  the  extraction  of  teeth,  and  by  the  fact  that  many  persons 
have  the  habit  of  carrying  a  straw  in  the  mouth  or  of  using  one  as  a 
substitute  for  a  toothpick. 

Pathology. — Proliferative  and  necrotic  osseous  changes  resulting 
from  this  form  of  infection  progress  within  the  central  portion  of  the 
bone  and  cause  resorption  of  surrounding  osseous  structures.  Sub- 
periosteal involvement  frequently  causes  marked  increase  in  the  size 
of  the  bones.     (See  Actinomycosis,  p.  129.) 


NECROSIS  OF  THE  JAWS  333 

Leprosy  of  Bone. — Leprosy  is  sometimes  marked  by  bone  inflam- 
mation and  necrosis.     (Sec  Leprosy,  p.  189.) 

Glanders. — Glanders  usually  attacks  the  periosteum,  but  may 
involve  the  hone  also.     (See  (Ilanders,  p.  134.) 

Mercurial  Necrosis. — Etiology .^ — Ptyalism,  interstitial  gingivitis,  peri- 
ostitis, and  necrosis  were  frequent  results  in  the  days  when  calomel 
was  extensively  used  by  the  laity  without  proper  prescription,  espe- 
cially in  malarial  districts.  The  same  results  are  not  infrequently 
noted  at  the  present  time  when  mercury  has  been  prescribed  for 
syphilis  and  when  by  continued  repetition  of  the  prescription  without 
medical  advice  excessive  doses  have  been  too  long  continued.  The 
inhalation  of  fumes  or  dust  containing  mercury  by  workmen  in  mirror 
factories  is  also  said  to  be  a  cause  of  chronic  poisoning.  Miners  work- 
ing in  mercury  mines  according  to  Talbot  are  usually  toothless  at  the 
age  of  thirty-five  years. 

Pathology. — In  acute  mercurial  poisoning  there  are  violent  inflam- 
n\atory  and  necrotic  lesions  of  the  gastro-intestinal  tract.  Degenera- 
tions of  the  renal  epithelium  and  other  organs  sometimes  occur.  In 
subacute  cases,  ptyalism  is  believed  to  be  due  to  pathological  change 
in  the  salivary  glands,  but  this  is  not  definitely  understood.  In  chronic 
cases  the  pericemental  tissues  in  common  with  overlying  and  surround- 
ing structures  undergo  degenerative  changes  which  render  them  par- 
ticularly susceptible  to  inflammation. 

Mercury  is  eliminated  by  active  stimulation  of  all  excretory  organs. 
When  elimination  is  insufficient  both  kad  and  mercury  accumulate 
in  the  system.  It  is  believed  that  they  form  albuminized  combinations 
in  the  tissues  with  resultant  affection  of  both  the  central  and  peripheral 
nervous  systems.  Trophic  changes  occur  which,  assisted  by  accumu- 
lation in  the  vessels,  cause  thickening  of  the  intima-tunica  and  result 
in  endarteritis  obliterans.  When  the  circulation  is  thus  impeded  and 
there  is  local  irritation  by  accumulation  in  the  vessels  with  weakened 
general  resistance,  owing  to  disturbance  of  the  eliminative  organs, 
degenerative  changes  result. 

Symptoms. — In  the  subacute  stage  there  is  an  excessive  flow  of 
saliva,  a  dark  bluish  line  forms  at  the  borders  of  the  gingivae,  the  gums 
become  swollen  and  everted,  the  teeth  loosened  and  elongated,  and 
these  symptoms  are  followed  by  the  discharge  of  pus  from  the  alveoli 
and  the  formation  of  pus  pockets  around  the  teeth.  Acute,  diffuse, 
suppurative  periostitis  with  symptoms  of  acute  inflammation  of  over- 
lying tissue  is  followed  by  the  formation  of  sequestra  of  bone  and 
complete  or  partial  necrosis.  'Accompanying  the  bone  destruction 
there  is  usually  extensive  ulceration  and  loss  of  the  soft  tissues  of  the 
mouth  which  may  involve  the  cheek,  muscles  of  the  soft  palate,  or  the 
oral  mucous  membrane.  Marked  contraction  and  scar  formation  is  a 
notable  feature  in  chronic  ulceration  of  this  character,  and  closely 
resembles  sj^hilitic  ulceration  in  this  respect. 


334  DISEASES  OF  BONE 

Diagnosis. — In  the  early  stages  differentiation  must  be  made  from 
interstitial  gingivitis  from  other  causes,  gangrenous  stomatitis,  acute 
leukemia,  pernicious  anemia,  and  sj^hilis.  The  history  of  the  case, 
blood  counts,  and  general  physical  examination,  or  the  Wassermann 
test,  where  no  clear  history  may  be  obtained,  usually  supply  the  dis- 
tinctive diagnostic  indications. 

Treatment. — Discontinue  the  administration  of  mercury  and  avoid 
exposure  to  mercury  in  any  form,  and  treat  the  same  as  any  other 
form  of  necrosis. 

Phosphorus  Necrosis. — Phosphorus  necrosis  was  a  common  type 
before  employees  in  large  factories  were  protected  from  the  fumes 
of  phosphorus. 

Etiology. — This  form  of  necrosis  is  due  to  the  contact  of  phosphorus 
or  its  fumes  with  the  periosteum  or  pericementum  of  the  roots  of 
teeth,  or  infection  by  microorganisms  in  a  state  of  weakened  bodily 
resistance  induced  by  the  poisonous  effect  of  the  phosphorus.  The 
chewing  of  matches  has  sometimes  been  recognized  as  a  cause.  It  has 
seldom  been  known  to  affect  the  mouths  of  persons  with  sound  teeth. 
Carious  teeth  and  those  otherwise  diseased  have  most  frequently  been 
held  responsible  for  its  occurrence. 

Pathology. — In  phosphorous  poisoning  there  is  catarrhal  inflam- 
mation of  the  gastro-intestinal  mucous  membrane  and  fatty  degenera- 
tion which  affects  the  liver,  other  internal  organs,  the  heart  muscle, 
and  intima  of  the  bloodvessels.  In  the  chronic  forms  catarrhal  inflam- 
mation of  the  respiratory  tract  paves  the  way  for  bone  infection,  and 
the  results  are  quite  similar  to  bone  necrosis  under  other  condi- 
tions. 

Symptoms.— The  only  sjTnptoms  of  phosphorus  necrosis  which 
might  be  considered  as  pathognomonic  of  this  form  of  necrosis  have 
been  claimed  to  be  the  peculiar  pumice-like  appearance  of  the  dead 
bone  and  the  fact  that  the  periosteum  becomes  unusually  resistant 
and  retains  its  \'itality  even  though  the  bone  undergoes  extensive 
osteoporous  necrosis.  The  author,  however,  has  noted  the  same  char- 
acteristic quite  frequently  in  necrosis  of  the  jaws,  where  there  was 
no  possibility  of  phosphorus  having  been  an  etiological  factor. 

Treatment.^ — Treatment  consists  of  prevention  of  exposure  to  phos- 
phorus, assisting  the  process  of  its  elimination  from  the  system,  and 
upbuilding  the  general  health  of  the  individual  to  increase  resistance 
and  aid  in  overcoming  the  effect  of  the  poison.  In  other  respects  the 
treatment  of  diseased  bone  is  the  same  as  for  other  forms  of  necrosis. 

Arsenical  Necrosis. — Etiology. — This  form  of  necrosis  has  usually 
been  caused  by  careless  application  of  arsenical  paste  for  the  devital- 
ization of  tooth  pulps.  Fortunately  cocain  pressure  anesthesia  for  the 
remo^'al  of  pulps  has  largely  done  away  with  danger  in  this  respect. 

Pathology. — The  powerful  escharotic  action  of  the  drug  in  contact 
\^ith  the  pericementum  or  periosteum  of  the  alveolar  structures  sur- 
rounding the  teeth,  and  particularly  the  bony  septum  between  the 


NECROSIS  OF  THE  JAWS  335 

roots  of  teeth,  excites  an  acute  inflammation  which  destroys  the  afi"ected 
bony  area. 

Symptoms. — The  s^Tiiptoms  include  discharge  of  pus,  exfohation  of 
small  i^ortions  of  bone,  and  occasionally  the  loss  of  one  or  more  teeth 
that  have  become  devitalized  and  loosened.  The  extensive  necrotic 
areas,  involving  the  soft  tissues  of  the  mouth  as  well  as  the  alveolar 
process,  which  have  been  reported,  were  probably  due  to  infection, 
since  the  action  of  arsenic  is  more  or  less  self-limiting. 

Treatment. — The  treatment  consists  in  complete  extirpation  of 
diseased  bone  and  soft  tissue,  and  the  local  application  of  tincture  of 
iodin  or  the  hydrated  oxide  of  iron,  which  it  has  been  claimed  will 
neutralize  the  eflfect  of  arsenic  in  the  tissue. 

In  all  other  respects  the  treatment  is  the  same  as  for  other  forms  of 
necrosis. 

Pathology. — When  a  mass  of  bone,  whether  large  or  small,  has  been 
destroyed  through  the  processes  described  in  connection  with  osteo- 
myelitis and  infection  from  periostitis  a  line  of  demarcation  is  formed 
between  the  living  and  dead  bone  which  is  quite  similar  to  that  of 
gangrene.  Where  the  dead  tissue  joins  the  living,  phagocytic  cells 
attack  the  osseous  matrix  forming  the  line  between  the  dead  and  living 
structures,  the  result  of  secretory  and  phagoc\1;ic  action  of  the  leuko- 
cytes and  osteoclasts  is  that  a  portion  of  dead  bone  becomes  separated 
from  the  living  bone  and  becomes  what  is  known  as  a  sequestrum. 
The  process  by  which  this  is  accomplished  is  called  exfoliation.  The 
newly  formed  bone  surrounding  the  sequestrum  is  called  the  involu- 
crum,  through  which  there  may  be  little  openings  called  cloacoe.  Sup- 
purative processes  extending  to  and  through  the  overlying  tissues  may 
form  a  sinus  or  sinuses  for  the  escape  of  pus,  or  the  sequestrum  may 
become  enclosed  in  masses  of  fibrous  or  osseous  tissue,  which  some- 
times hold  and  prevent  its  exfoliation  and  in  this  way  give  rise  to 
chronic  conditions  that  sometimes  persist  for  many  years.  Some- 
times liquefaction  of  tissue  takes  place  without  the  formation  of  a 
sequestrum,  there  being  a  continued  softening  and  crumbling  of  the 
bone  which  either  becomes  roughened  with  more  or  less  excavated 
areas  upon  the  surface  or  a  softened  mass  within  the  bone.  This  we 
recognize  as  caries. 

Ssrmptoms. — ^The  symptoms  of  necrosis  of  the  jaws  are  necessarily 
modified  by  the  character  of  the  cause.  Traumatic  injury  would  be 
evidenced  by  inflammation  of  the  periosteum  in  common  \^■ith  over- 
lying injured  parts.  Infection  from  an  acute  dento-alveolar  abscess 
would  present  the  predominant  symptoms  of  this  affection  during  the 
early  stages.  In  all  the  non-traumatic  or  so-called  idiopathic  cases 
there  are  present  the  symptoms  of  acute  infectious  diseases.  These 
vary  greatly,  according  to  the  severity  of  the  infection,  resistance 
of  the  individual,  and  conditions  governing  the  actual  cause.  There 
may  be  chills,  fever,  prostration,  temperature  ranging  from  101°  to 
105°  F.,  or  even  higher,  with  severe  local  pain  and  great  prostration. 


336  DISEASES  OF  BONE 

The  toxemia  may  be  so  rapid  as  to  cause  delirium,  stupor,  endocarditis 
and  death,  or  there  may  be  acute  local  pain  with  but  slight  evidence 
of  general  symptoms  and  infection,  or  subacute  and  chronic  perios- 
titis, osteomyelitis,  or  ostitis  may  lead  to  the  destruction  of  large 
areas  of  bone  with  almost  no  serious  objective  symptoms  and  complete 
absence  of  pain,  until  in  due  course  there  is  formation  of  pus  and  the 
final  exfoliation  of  the  bone.  Tenderness  to  touch  over  a  more  or 
less  considerable  area  which  is  marked  by  redness  is  usually  an  early 
symptom. 

Caries  of  bone,  being  a  slower  process,  is  usually  unattended  by 
painful  symptoms  other  than  those  incident  to  acute  infections, 
which  may  be  the  first  cause  of  the  formation  of  the  bone  abscess. 
The  most  common  cause  of  caries  in  the  maxillary  bones  is  dento- 
alveolar  abscess,  which,  having  become  chronic,  proceeds  slowly  with 
bone  disintegration  until  considerable  excavations  in  the  bone  have 
been  accomplished. 

Diagnosis. — \Yhen  sequestra  of  bone  have  been  formed  there  is 
usually  discharge  of  pus,  which  by  making  pressure  upon  the  over- 
lying surface  may  be  seen  to  exude  through  se\'eral  fistuhie.  Touched 
with  a  probe  or  suitable  instrument,  such  bone  will  be  found  to  have 
lost  its  velvety  feeling  and  is  rough.  Usually  slight  motion  of  the 
sequestrum  can  be  detected.  In  carious  conditions  due  to  extensive 
and  long-continued  chronic  abscesses  the  external  bony  wall  will 
usually  be  found  to  be  extremely  thin  and  yielding  to  pressure.  It  is 
this  characteristic  which  often  serves  to  indicate  the  existence  of  a 
carious  area  that  would  not  otherwise  be  suspected.  Surrounding  bone, 
not  yet  fully  disentegrated  but  \\ithout  normal  vitality,  is  also  recog- 
nized by  its  rough  dead  feeling.  Perhaps  in  no  other  part  of  the  body 
is  recognition  of  the  exact  cause  of  necrosis  so  necessary  or  difficult. 
The  differentiation  of  different  diseases  and  forms  of  infection  through 
which  the  local  disease  might  have  been  caused  is  equally  important 
in  all  fields  of  practice,  but  on  account  of  the  multiplicity  of  causes  of 
diseases  of  the  teeth,  and  the  great  variety  through  which  infection 
might  occur,  careful  distinction  is  exceedingly  necessary. 

Treatment  of  Necrosis  and  Caries. — ^In  the  acute  stages,  when 
pain  and  other  s}inptoms  of  acute  inflammation  are  present  and  before 
Nature  has  had  an  opportunity  to  complete  the  process  of  separation 
between  dead  and  living  bone,  treatment  is  limited  to  measures  which 
relieve  the  pain,  check  the  progress  of  the  inflammation,  and  if  possible 
abort  the  formation  of  complete  necrosis.  Sources  of  infection  or 
irritation  must  be  brought  within  control  or  at  least  receive  appro- 
priate attention.  Incision  through  the  overlying  tissues  and  perios- 
teum down  to  the  bone  may  be  necessary  to  check  the  progress  of 
an  acute  diffuse  suppurative  periostitis.  Painting  the  surface  with 
tincture  of  iodin  serves  the  double  purpose  of  antisepsis  and  local 
absorption.  Hot  applications  in  the  form  of  capsicum  plasters,  or 
similar  agents  applied  to  the  mucous  membrane  surface  immediately 


NECROSIS  OF  THE  JAWS  337 

over  the  point  of  greatest  tenderness  somethnes  give  relief  and  facili- 
tate the  progress  of  pus  toward  the  surface,  and  this  aids  more  com- 
plete relief.  IIot-Avater  bags  or  hot  fomentations  applied  to  the  face 
are  always  gratifying  and  sometimes  quite  beneficial.  Relief  of  pain 
by  the  use  of  hypodermic  injections  of  codeine  or  morphin  or  the 
internal  administration  of  suitable  remedies  is  occasionally  necessary 
to  tide  over  the  period  until  surgical  relief  may  be  given.  All  the 
bodily  eliminative  processes  should  be  called  into  action.  Cathartics, 
diuretics,  and  sudorifics  should  be  administered  if  required;  usually, 
however,  the  increased  activity  of  the  kidneys  and  sweat  glands  may 
be  more  naturally  stimulated  by  free  administration  of  warm  drinks, 
hot  foot  baths,  warmth  to  the  surface  of  the  body,  etc.  The  bodily 
temperatiu-e  should  be  carefully  noted,  and  the  degree  of  fever,  which 
in  the  acute  fulminating  cases  is  sometimes  high,  may  be  taken  as  an 
index  of  the  relative  virulence  of  the  infection  and  bodily  resistance 
of  the  indi^'idual.  Cold  sponge  baths,  sponging  with  tepid  water 
followed  with  alcohol,  and  high  bowel  flushing  offer  the  most  satis- 
factory means  of  controlling  the  fever,  which  after  all  is  only  one  of 
nature's  means  of  fighting  the  infection  and  should  not  be  masked  by 
the  use  of  antipyretics  or  other  drugs,  the  ultimate  effect  of  which  is 
almost  invariably  bad. 

Nourishment  should  be  in  concentrated,  higlil}-  nourishing,  easily 
digested  form,  ^^^len,  as  sometimes  happens,  the  entire  digestive 
tract  becomes  so  disturbed,  as  to  make  the  administration  of  food  by 
stomach  inadvisable,  then  rectal  nourishment  should  be  given  and 
supplemented  by  frequent  administrations  of  normal  salt  by  rectum 
slowly,  according  to  the  drop  method. 

Virulent  infection  with  weakened  bodily  resistance  frequently  leads 
to  toxemia  of  serious  nature,  and  ill-advised  attempts  to  give  surgical 
relief  through  opening  the  vessels  to  direct  entrance  of  infection  has 
been  known  to  result  in  true  septicemia  and  pyemia.  In  all  such  cases 
the  effect  of  general  septic  infection  must  be  combated  in  addition  to 
local  treatment.  H^•podermoclysis  (the  administration  of  the  normal 
salt  subcutaneously  into  the  tissues)  is  required  in  the  graver  cases  of 
this  affection  to  stimulate  depleted  vital  forces.  Intravenous  admin- 
istration of  normal  salt  is  also  recommended  as  giving  a  more  direct 
and  therefore  more  prompt  and  efficient  effect.  Transfusion  of  blood 
when  performed  by  a  proper  technic  and  sufficiently  safeguarded  is 
undoubtedly  the  most  effective  means  of  combating  every  form  of 
septicemic  or  pyemic  condition. 

\Mien  actual  disintegration  of  bone  has  been  accomplished  the 
treatment  briefly  outlined  is  as  follows: 

1.  Correction  of  the  cause. 

2.  Relief  of  pus. 

3.  Sterilization,  local  antiseptic  treatment  to  prevent  extension. 

4.  Removal  of  Dead  Bone. — Distinction  must  be  made  between 
necrosis  and  caries  in  treatment.     A  sequestrum  or  sequestra  should 

22 


338  DISEASES  OF  BONE 

be  taken  out  intact  if  possible.  Carious  bone  must  be  removed  with 
a  surgical  or  dental  engine  bur,  a  chisel,  or  curette,  and  all  roughened 
bone  borders  made  smooth.  This  distinction  is  very  necessary  because 
an  attempt  to  get  out  a  sequestrum  of  bone  with  a  dental  bur  would 
only  result  in  breaking  up  little  particles  of  bone  and  forcing  them 
into  the  tissues,  thus  leading  to  continuation  instead  of  relief  of  the 
disease.  After  the  sequestrum  has  been  removed  the  bone  borders 
may  be  smoothed  by  the  use  of  a  10  to  25  per  cent,  solution  of  sul- 
phuric acid  or  better  still  with  a  curette,  and  all  carious  bone  removed 
until  the  smooth  velvety  surface  of  healthful  bone  can  be  recognized. 

5.  Packing. — If  the  cavity  in  the  tissuse  remaining  after  the  dead 
bone  has  been  dislodged  or  cut  away  is  of  such  form  or  situation  as  to 
be  unfavorable  to  drainage,  then  it  may  be  necessary  to  insert  a  pack- 
ing. This  is  best  done  with  gauze,  because  cotton  is  likely  to  leave 
threads  behind  to  continue  irritation  and  infection  afterward.  The 
gauze  should  be  wrung  out  in  a  2.5  per  cent,  carbolic  acid  solution, 
1  to  10,000  mercuric  bichloride,  10  per  cent,  tincture  of  iodin,  or  some 
similar  antiseptic,  and  sealed  in  with  collodion  or  gutta-percha  dis- 
solved in  chloroform.  Once  each  day  this  should  be  changed  to  avoid 
infection. 

When  the  wound  cavity  can  be  made  sufficiently  open  and  saucer- 
shaped  to  facilitate  natural  drainage  and  prevent  lodgment  of  disad- 
vantageous agents  this  should  be  done,  and  then  no  packing  ought  to 
be  used ;  but  the  frequent  holding  in  the  mouth  of  dioxogen,  or  any  of 
the  well-known  suitable  germicidal  agents,  must  be  depended  upon  to 
prevent  infection. 

General  treatment  is  often  required  to  overcome  the  toxic  effect 
of  the  disease.  Ovoferrin,  other  forms  of  iron,  quinine,  cod-liver  oil, 
and  tonics  are  often  valuable. 

Diseases  such  as  syphilis,  tuberculosis,  actinomycosis,  leprosy,  and 
glanders  must  each  receive  its  own  special  treatment  as  indicated  in 
addition  to  the  local  treatment. 

FRACTURES   OF  THE  JAWS. 

A  fracture  may  be  defined  as  a  break  in  the  continuity  of  bone  or 
cartilage  caused  by  direct  force  or  muscular  contraction. 

Varieties  of  Fractures. — Complete. — 1.  Simyle. — A  single  fracture 
without  division  of  the  overlying  soft  tissues. 

2.  CompoinuL- — Fracture  with  broken  bone  surfaces  exposed  to 
the  external  air  by  division  of  the  overlying  parts. 

3.  Ahdtiple. — Two  or  more  distinct  fractures  of  the  same  bone. 

4.  Comminuted. — A  fracture  in  which  the  bone  is  crushed  or  broken 
into  small  communicating  fragments. 

5.  ComiMcated. — A  term  usually  applied  to  fracture  accompanied 
by  some  serious  injury  of  the  parts  in  the  region  of  the  fracture,  as 
important  nerves,  bloodvessels,  joints,  etc. 


FRACTURES  OF  THE  JAWS  339 

6.  Impacted. — When  the  fractured  fragments  of  bone  are  driven 
into  each  other  and  more  or  less  embedded. 

Fractures  are  further  described  by  the  following  self-explanatory 
terms:     Tran\'erse,  oblique,  longitudinal,  dentated,  spiral. 

Incomplete  Fractures. — (Ireen-stick  fracture  or  partial  separation 
of  the  bone  fibers  allows  the  bone  to  bend,  but  it  is  not  completely 
broken  off. 

Other  forms  of  incomplete  fracture  are  described  as : 

Fissured.  Punctured. 

Indented  or  depressed.  Perforating. 

Special  Forms  of  Fracture. — Fractures  not  invariably  or  distinctly 
within  either  of  the  foregoing  classes  are: 

Pathological  Fractures. — This  is  due  to  preexisting  disease,  as  from 
some  constitutional  condition  affecting  tbe  bone  structure,  fragilitas 
ossium,  sarcoma,  cancer,  senile  atrophy,  etc. 

Subperiosteal  Fracture. — Fracture  of  the  bone  sometimes  occurs 
without  separation  of  the  periosteum  in  cases  of  infants  and  very 
young  children. 

Gunshot  Fracture. — Gunshot  fractures  necessarily  depend  upon 
velocity,  character  of  the  missile,  and  the  kind  of  bone  at  the  seat 
of  injury.  Cancellated  structures  yield  to  pressure  without  extensive 
lateral  injury.  Compact  bone  structures  such  as  in  the  lower  jaw  are 
likely  to  suffer  extensive  comminution  with  fissured  fractures.  Splin- 
ters of  bone  may  also  be  forced  in  different  directions  and  the  size 
of  the  wound  materially  increased. 

Alveolar  Fractures. — ^This  form  consists  in  splitting  or  fracture  of 
the  alveolar  process  not  involving  other  portions  of  the  maxillary  bones. 
Intra-uterine  Fractures.— The  weakened  osseous  system  of  the  off- 
spring of  mothers  affected  by  scurvy,  syphilis,  and  struma  may  some- 
times suffer  fracture  before  birth.  This  does  not  include  injury  by 
instruments  in  delivery. 

All  fractures  are  also  described  as: 

Recent.  Old. 

United.  Ununited. 

Etiology. — Superior  Maxilla. — ^The  superior  maxillse  with  the  malar, 
nasal,  palate,  lacrimal,  ethmoid,  and  sphenoid  bones  form  an  almost 
indivisible  complement  in  the  bony  structure  of  the  upper  part  of  the 
face,  which  is  greatly  exposed  to  traumatic  injury.  It  is,  nevertheless, 
true  that  these  other  bones  serve  to  protect  the  maxillse,  so  that  frac- 
tures of  the  upper  jaw  are  comparatively  rare.  They  usually  result 
from  more  or  less  unusual  force  directly  applied,  such  as  the  kick  of  a 
horse,  falling  upon  the  face  or  from  some  height,  runaway,  automobile, 
motor  cycle,  and  similar  accidents,  gunshot  injuries  of  the  mouth,  and 
not  infrequently  when  the  lower  jaw  is  forcibly  driven  against  the 
upper. 

Inferior  Maxilla. — The  inferior  maxilla,  because  of  its  exposed  situa- 
tion, its  size,  and  shape,  is  much  more  subject  to  fracture  than  the 


340  DISEASES  OF  BONE 

superior  maxilla,  or,  in  fact,  any  other  bone  of  the  face.  The  weakest 
point  in  a  normal  lower  jaw  is  generally  recognized  as  being  slightly 
anterior  to  the  mental  foramen  and  in  an  edentulous  jaw  at  or  in 
line  with  the  mental  foramen.  Naturally  these  are  the  points  at 
which  fracture  most  frequently  occurs.  Fractures  in  this  region  are 
quite  common  because  of  exposure  of  the  likelihood  of  blows  upon  the 
face  or  neck  affecting  the  side  of  the  jaw,  and  also  because  in  such  large 
numbers  of  people  the  first  molars  or  bicuspids  have  been  lost  with 
corresponding  absorption  of  the  alveolar  structures  to  weaken  the  jaw. 
At  the  angle  of  the  jaw  fracture  is  also  quite  frequent.  Many  cases  of 
fracture  in  this  region  have  been  reported  from  extraction  of  third 
molar  teeth,  especially  when  impacted.  Beyond  this  general  charac- 
terization the  exact  order  of  frequency  in  the  occurrence  of  fractures 
through  the  symphysis,  the  ramus,  the  neck  of  the  condyle,  and  the 
coronoid  processes,  situations  in  which  fractures  of  the  mandible  may 
occur,  is  according  to  the  author's  experience  too  uncertain  to  warrant 
definite  statements. 

Symptoms. — Symptoms  of  fracture  of  the  jaws  are:  (1)  Deformity, 
(2)  unnatural  mobility,  (3)  crepitus,  (4)  loss  of  function;  (5)  pain, 
which  may  be  constant  or  only  on  movement  of  the  jaws,  or  the  frac- 
tured ends  of  the  bone;  and  (6)  in  compound  cases  the  fractured  ends 
of  the  bone  may  project  into  the  mouth  through  the  wound  in  the  soft 
tissues. 

Swelling  and  other  s^Tuptoms  are  dependent  upon  the  extent  of 
trainnatic  injury  and  infection. 

Diagnosis. — The  distortion  of  facial  features  may  be  sufficiently 
indicative  without  other  s^anptoms.  Quite  often  this  is  disguised  by 
swelling  of  the  overlying  soft  tissues.  When  there  are  teeth  in  the  jaws 
disarrangement  of  occlusion  is  usually  a  marked  and  important  sjnnp- 
tom.  The  teeth  upon  one  side  of  the  line  of  fracture  may  be  higher 
or  lower  than  those  upon  the  other,  or  they  may  be  out  of  alignment 
in  a  lingual  or  buccal  direction  with  deformity  still  more  evident.  By 
firmly  grasping  the  bone  upon  each  side  of  the  seat  of  injury  unusual 
motion  is  usually  detected,  and  the  crackling,  scraping  sound  (crepitus), 
as  the  ends  of  the  bone  are  rubbed  against  each  other,  completes  the 
diagnosis. 

Fractures  of  the  Superior  Maxillse. — Injury  sufficient  to  cause  fracture 
in  the  upper  jaw  is  usually  so  severe  and  the  bone  so  broken  into  differ- 
ent portions  that  diagnosis  is  quite  simple.  Nevertheless,  upper  jaws 
have  frequently  been  broken  and  the  fact  was  not  discovered  until  long 
after  union  had  taken  place  with  marked  deformity  of  the  dental  arches. 
This  has  occurred  in  many  instances  because  fracture  of  the  superior 
maxilla  occurred  simultaneously  with  that  of  other  bones  of  the  face, 
the  latter  masking  the  maxillary  fracture  and  causing  it  to  be  over- 
looked. 

Notwithstanding  the  frequency  of  comminuted  fractures  of  the 
upper  jaw,  an  attempt  has  been  made  to  recognize  certain  definite 


FRACTURES  OF  THE  JAWS  341 

fracture  lines.  Thus  a  transverse  fracture  has  been  described  by  Guerin 
which  extends  backward  along  both  sides  of  the  upper  jaw  below  the 
niahir  bones  initil  it  includes  the  pterygoid  processes.  The  roof  of 
the  mouth,  including  the  teeth,  drops  down  until  it  rests  upon  the  floor 
of  the  mouth  and  is  to  some  extent  displaced  in  a  backward  direction. 
This  form  of  fracture  quite  frequently  occurs  from  blows  upon  the  face 
just  below  the  nose.  In  one  of  the  author's  cases  it  Mas  caused  by  the 
kick  of  a  mule.  Fracture  closely  associated  \Aith  diastasis  of  other 
bones  of  the  face  is  usually  evidenced  by  division  through  the  median 
palatal  suture,  and  is  caused  by  accidents  which  jar  or  drive  the  lower 
jaw  forcibly  into  the  upper  in  such  manner  as  to  force  the  maxillae 
apart.  In  one  of  the  author's  cases  there  was  an  opening  through  the 
hard  palate  with  division  of  the  soft  tissues  ^^■hen  the  bones  were 
forced  apart  and  disarticulation  of  the  zygomatical  maxillary  suture 
was  revealed  when  the  infra-orbital  outline  was  followed  with  the  finger. 
The  separation  between  the  maxillary  bones  was  also  evident  at  the 
intermaxillary  suture  and  by  space  between  the  central  incisor  teeth. 
In  another  case,  a  patient  of  Dr.  G.  W.  Fox,  of  ^Milwaukee,  an  auto- 
mobile accident  had  caused  similar  fracture  with  diastasis  of  nearh'  all 
the  facial  bones,  accompanied  also  by  fracture  of  the  malar  bones. 
Force  applied  against  the  upper  jaw  obliquely  outward  or  upward 
upon  the  side  causes  splitting  of  the  alveolar  process  and  occasionally 
oblique  fractures  extending  deep  into  the  body  of  the  bone.  Alveolar 
fractures  are  quite  commonly  incidental  to  extraction  of  teeth. 

Fractures  of  the  Inferior  Maxilla. ^ — Ordinarily  fractures  of  the  lower 
jaw  present  typical  and  therefore  easily  recognized  symptoms.  ^Yhen 
caused  by  falling  and  striking  upon  or  blows  at  the  point  of  the  chin, 
which  tend  to  drive  the  jaw  backward  and  upward,  there  is  displace- 
ment of  the  mandible  in  a  backward  direction.  This  may  be  caused 
by  fracture  of  one  or  both  condyles  or  fracture  of  the  anterior  wall  of 
the  external  auditor}'  meatus,  and  in  these  cases  occasionally  the 
difTerentiation  is  somewhat  difficult.  Fractures  of  the  condyloid  pro- 
cesses usually  occur  at  the  neck.  If  upon  one  side  only,  there  is  dis- 
location of  the  chin  and  jaw,  which  are  pulled  toward  the  injured  side, 
chiefly  because  of  the  action  of  the  internal  pterygoid  muscle  of  the 
opposite  side.  Unilateral  fracture  of  the  neck  of  the  condyloid  pro- 
cess is  distinguished  from  dislocation  of  the  jaw,  because  in  these  cases 
the  jaw  is  drawn  toward  the  normal  side.  ^Yhen  both  condyloid  pro- 
cesses are  broken  the  lower  jaAV  is  drawn  upward  and  backward  and 
there  is  more  or  less  loss  of  mo^'ement  with  tendency  to  necrosis. 
When  the  condyles  are  intact,  but  in  being  driven  backward  have 
caused  fracture  of  the  anterior  wall  of  the  external  auditory  meatus, 
the  most  marked  s^Tiiptom  is  occlusion  of  the  external  auditory  canal 
when  the  jaws  are  closed  or  the  mandible  forced  backward. 

Fracture  of  the  glenoid  cavity,  which  is  necessarily  associated  with 
this  condition,  may  become  serious  if  inflammatory  processes  are 
excited  by  infection  and  lead  to  permanent  ank}'losis.     There  is  slight 


342 


DISEASES  OF  BONE 


depression  in  front  of  the  external  auditory  meatus;  the  broken  articu- 
lar surface  of  the  condyle  may  be  pulled  forward  and  inward  by  the 
external  pterygoid  muscle,  and  can  be  felt  by  drawing  the  jaw  forward 


Fig.  166. — Radiogram  of  the  jaw  of  a  young  woman,  one  of  the  author's  cases.  This 
fracture  through  the  lower  jaw  resulted  from  an  ill-advised  attempt  to  extract  an 
impacted  third  molar  in  a  dental  office. 


Fig.  167. — Fracture  of  tooth  and  jaw.    The  tooth  becomes  infected  in  such  cases  and 
must  be  removed.     (Dunning.) 

and  pressing  the  condyle  from  within  outward  with  a  finger  placed 
upon  the  upper  lateral  wall  of  the  pharynx.  Such  fractures  may 
sometimes  be  reduced  in  this  way. 


FRACTURES  OF  THE  JAWS 


343 


Fig.   1G8. — Impacted  cuspid  in  line  of  fracture;  a  predisposing  cause  and    an  obstacle 
to  healthy  repair  of  bone.     (Dunning.) 


Fig.  169. — Pathological  fracture;  no  history  of  any  trauma,  but  long  history  of 
chronic  abscesses  of  jaw.  Fracture  occurred  while  patient  was  eating  crust  of  bread. 
(Dunning.) 


344  DISEASES  OF  BONE 

Fractures  at  the  Symphysis. — Fractures  through  the  symphysis 
are  usually  vertical  and  cause  comparatively  little  dislocation.  With 
fractures  of  the  coronoid  processes  the  symptoms  are  usually  slight 
except  when  the  jaw  is  moved  extensively.  This  form  of  fracture 
is  exceedingly  rare,  and  is  always  accompanied  by  fracture  of  other 
bones.  Its  existence  would  therefore  only  be  suspected  under  such 
conditions  and  when  the  injury  was  of  such  direct  character  as  to  make 
such  injury  possible.  Palpation  by  the  fingers  \\ithin  the  mouth 
usually  leads  to  discovery. 

Fractures  of  the  ascending  ramus  are  rare  because  it  is  well  covered 
with  muscles.  They  can  best  be  felt  from  within  the  mouth  and  by 
passing  the  finger  along  the  posterior  border  of  the  ramus  externally. 

In  most  cases  fracture  of  the  lower  jaw,  can  be  distinguished  by 
the  break  in  the  natural  outline,  v/hich  is  felt  by  passing  a  finger  along 
the  lower  and  posterior  border.  By  all  means  the  most  perfect  diag- 
nostic aid  in  doubtful  conditions  are  the  .r-rays,  by  which  not  only  the 
existence  of  fracture  may  be  established  but  its  exact  character  as  well. 

Treatment  of  Fracture  of  the  Maxillae. — The  methods  of  retaining 
fractured  lower  jaws  are  as  follows:  (1)  By  bandaging  alone;  (2)  by 
ligating  teeth  upon  each  side  of  the  fracture  as  first  done  by  Hippo- 
crates and  used  in  one  form  or  another  ever  since;  (3)  by  splints  con- 
structed of  metal,  plaster  of  Paris,  or  other  suitable  material  laid  upon 
the  external  surface  of  the  chin,  the  side  of  the  jaw  or  behind  the  angle 
with  a  few  layers  of  cotton  pad  to  prevent  irritation  and  firmly  ban- 
daged; (4)  by  interdental  splints,  i.  e.,  supports  placed  betA\een  the 
jaws,  a  method  first  used  by  Hayward  in  1858  and  modified  and  im- 
proved by  Gunning  in  1861 ;  (5)  by  attachments  to  or  upon  the  teeth  of  the 
affected  jaiv  only;  (6)  by  wiring  the  teeth  of  both  jaws  together;  and.(7)  by 
wiring  the  hones,  of  which  a  successful  case  was  reported  by  Buck,  1847. 

In  deciding  upon  the  splint  or  appliance  that  may  be  used  to  hold 
the  fractured  bony  parts  in  position  there  are  certain  important  prin- 
ciples which  must  be  kept  in  view  to  govern  selection.  These  in  the 
order  of  their  relative  importance  are  as  follows:  (1)  Perfect  approxi- 
mation of  the  parts;  (2)  immohility;  i^i)  freedom  in  taking  nourishment; 
(4)  facility  in  keeping  the  mouth  surfaces  clean;  (5)  the  possibility  of 
frequent  observation  of  the  parts;  and  (6)  freedom  in  the  use  of  the  jaws, 
which  necessarily  implies  their  not  being  bandaged  or  bound  together 
by  wires. 

In  some  forms  of  fractures  all  of  these  desirable  conditions  can  be 
secured,  and  in  others  this  is  impossible.  It  therefore  becomes  necessary 
to  select  the  kind  of  splint  that  will  give  the  greatest  possible  comfort 
to  the  patient  with  the  best  promise  of  a  good  result  by  securing  as 
many  of  these  advantages  as  may  be  practicable.  A  vast  amount  of 
ingenuity  has  been  expended  upon  different  forms  of  appliances  for 
retaining  fractured  jaws.  An  attempt  at  enumerating  and  describing 
them  would  be  both  impractical  and  unnecessary  if  the  foregoing 
principles  are  kept  in  mind.     Selection  may  be  made  from  a  few 


FRACTURES  OF  THE  JAWS  345 

simple,  thoroughly  practical  forms,  which  can  be  modified  so  as  to  be 
adapted  to  almost  any  variety  that  may  occur.  The  illustrations  and 
descriptions  are  therefore  confined  to  these  examples. 

First  aid  in  these  cases  depends  largely  upon  the  character  of  the 
injury  and  the  condition  of  the  patient  at  the  time  treatment  is  begun. 
Many  times  the  shock  attendant  upon  the  accident,  concussion  by 
injury  to  the  head,  or  complications  make  it  necessary  to  be  content 
with  such  temi)orary  measures  as  may  give  the  best  possible  immediate 
relief  with  a  view  to  more  accurate  and  effective  treatment  when  other 
conditions  are  more  favorable,  In  one  of  the  author's  cases,  for 
example,  a  man  was  butted  through  a  fence  by  a  bull,  and  in  addition 
to  the  fracture  of  the  jaw,  suffered  fractured  ribs,  also  with  traumatic 
injury  to  the  lungs,  v\hich  brought  about  a  pneumonia  and  temporarily 
endangered  his  life.  In  the  absence  of  grave  general  obstacles,  the 
swelling  of  the  parts,  ^\■ith  attendant  pain  and  soreness  in  manipula- 
tion and  difficulty  in  opening  the  mouth,  sometimes  renders  perfect 
adjustment  at  the  time  impossible.  In  these  cases  for  temporary  pur- 
poses and  to  hold  the  parts  during  the  period  necessary  for  the  prepara- 
tion of  a  proper  permanent  support,  an  interdental  splint  is  valuable. 
It  is  made  of  modelling  compound,  softened  in  warm  water,  molded 
into  proper  form,  placed  between  the  jaws  and  held  there  a  few  minutes 
until  it  hardens,  then  removed  and  trimmed  into  suitable  form  "with  an 
opening  in  the  anterior  part,  as  shown  in  Fig.  172.  It  serves  an  excel- 
lent purpose  by  retaining  the  fractiu'ed  bone  in  comfortable  position 
when  it  is  properly  placed  and  the  jaws  are  securely  bandaged,  until 
such  time  as  a  permanent  substitute  may  be  inserted.  A  few  cakes 
of  dentist's  modelling  compound  should  be  part  of  the  equipment  of 
every  surgeon's  case. 

The  author's  experience  in  one  instance,  however,  may  serve  to 
impress  the  need  of  caution  in  one  respect.  In  this  case  the  modelling 
compound  splint  was  left  in  place  longer  than  usual  on  account  of  the 
precarious  general  condition  of  the  patient  due  to  the  accidental  injury. 
Directions  were  given  at  the  hospital  to  have  the  mouth  freeh'  irrigated 
through  the  opening  in  the  anterior  part  of  the  splint.  Upon  returning 
several  days  later,  it  was  found  that  warm  water  had  been  used  and  the 
compound  softened  until  both  shape  and  usefulness  were  lost.  Irriga- 
tion with  antiseptic  solutions  may  be  freely  given  without  disturbing 
the  splint,  but  such  solutions  should  always  be  cold  whenever  model- 
ling compound  is  the  material  from  which  the  splint  is  made. 

Reduction  of  the  Fracture. — Antagonism  chiefly  due  to  the  digastric, 
geniohyoglossus  and  mylohyoid  muscles  upon  the  one  hand,  and  the 
masseter,  temporal,  and  the  pterygoid  muscles  upon  the  other,  when 
lost  by  a  fracture  of  the  jaw,  if  the  parts  are  sufficiently  separated  to 
lose  resistance  cause  more  or  less  marked  disarrangement.  Naturally 
this  is  greater  when  the  fracture  is  double  or  comminuted,  or  when  a 
segment  of  bone  is  actually  lost.  Under  favorable  conditions  the 
manipulation  necessary  for  production  and  proper  alignment  is  accom- 


346 


DISEASES  OF  BONE 


plished  with  comparatively  little  pain  and  without  much  difficulty. 
Sometimes,  however,  the  pain,  tense  contraction  of  the  muscles  due 
to  irritation,  extreme  nervousness  of  the  patient,  and  swelling  or  other 


Fig.  170. — a,  cast  of  the  mouth  of  one  of  the  author's  patients,  showing  Une  of  fracture 
through  the  lower  jaw,  with  typical  disarrangement  of  the  occlusion  of  the  teeth;  b,  the 
same  case  after  treatment. 


Fig.  171. — Fractured  lower  jaw,  with  characteristic  deformity.     (After  von  Bergmann.) 


unfavorable  symptoms  resulting  from  injury,  make  satisfactory 
adjustment  without  general  anesthesia  practically  impossible.  In  the 
absence  of  contra-indication,  ether  should  be  administered   in  order 


FRACTURES  OF  THE  JAWS 


347 


that  accurate  satisfactory  reduction  of  the  fracture  may  be  accom- 
plished \\'ith  complete  muscular  relaxation  (Figs.  170  and  171). 


Fit;.   172. — Gunning's  interdental  splint,  with  opening  for  introducing  food. 

Methods  of  Fixation. — Transverse,  comminuted,  or  multiple  fractures 
of  the  upper  jaw  require  general  support,  which  may  be  given  by 
binding  the  loA\er  jaw  firmly  against  the  upper  if  the  occlusion  of  the 
teeth  prior  to  the  accident  was  sufficiently  regular.  The  difficulty  in 
administering  nourishment,  which  must  be  given  through  a  tube, 
passed  along  the  buccal  surfaces  of  and  behind  the  molar  teeth,  through 


Fig.  173. — Radiograph  of  one  of  the  author's  patients,  a  boy  twelve  years  old,  run 
over  by  an  automobile.  Fracture  between  the  cuspid  and  lateral  incisor  teeth  on  the 
right  side,  and  in  the  region  of  the  first  molar  on  the  left  side  is  shown  held  in  fixation 
by  a  cast  aluminum  interdental  splint. 

the  nose,  or  in  a  limited  way  per  rectum,  is  an  objection  to  this  method. 
The  old-fashioned  interdental  splmt  (Fig.  172)  made  of  vulcanized 
rubber  gives  the  necessary  support,  allows  nourishment  to  be  taken 
through  the  opening  in  the  splint,  and  permits  of  fairly  satisfactory 
cleansing  by  irrigation. 

Kingsley's  interdental  splint  (Figs.  175  and  176),  as  modified  and 
described  by  Marshall,  is  made  of  rubber  vulcanized  upon  an  impression 


348 


DISEASES  OF  BONE 


of  the  upper  teeth  against  which  the  lower  jaw  has  been  pressed 
sufficiently  to  mark  the  outline  of  the  crowns  of  their  occlusal  surfaces. 
Wires  have  been  imbedded  into  the  sides  and  so  bent  as  to  pass  out 
around  the  angles  of  the  mouth  and  extend  outside  the  cheek  surfaces. 


^ 

^w 

■ 

I^K 

_^^^ 

^H 

ji 

H^Si 

^  -       ,^1^ 

^^ij^H 

M 

^^S 

w      ^^% 

^»^«|^^^^^^B 

1 

§ 

wt^^^m         ^i^B^.~  '^ 

F 

Fig. 


174. — Modification  of  the   Gunning  interstitial   splint   as  used  by   Dunning   for 
edentulous  upper  jaw,  when  lower  bicuspids  and  molars  are  also  missing. 


The  wires  make  it  possible  to  bind  the  appliance  with  elastic  or  other 
bands  passed  over  the  head  in  such  manner  as  to  support  the  fractured 
upper  jaw  without  restricting  movement  of  the  lower  jaw.  It  has  the 
additional  ad^'antage  of  permitting  constant  observation,  cleansing 


Fig.   175. — Kingsley's  interdental  splint. 


and  local  treatment  of  the  parts,  as  well  as  freedom  in  taking  food. 
When  a  sufficient  portion  of  the  upper  jaw  is  left  firm  and  immovable, 
a  metal  splint  cemented  to  the  teeth  (Fig.  177)  may  be  employed  as  in  the 
case  of  the  lower  jaw  (except  that  it  is  in  reverse  position),  with  almost 


FRACTURES  OF  THE  JAWS 


349 


entire  absence  of  discomfort  and  full  functional  possibility.  P>ven 
though  there  may  be  diastasis  of  facial  bones  with  fracture  of  the 
malar,  the  condition  is  not  necessarily  a  serious  one  from  the  stand- 
point of  retention.     In  some  of  the  author's  cases  the  molding  of  the 


Fig.  176. — Kingsley's  splint  applied. 


parts  and  adjustment  of  the  bones  by  pressure  was  sufficient,  and  only 
slight  support  secured  by  adhesive  plaster  laid  upon  the  surface  to 
make  slight  tension  in  the  desired  direction  or  properly  adjusted  band- 
ages, and  keeping  the  patient  as  nearly  absolutely  quiet  as  possible 
for  a  sufficient  time,  was  required. 


Dental  splint  applied  to  cast. 


The  method  of  wiring  the  lower  to  the  upper  teeth  to  secure  fractured 
jaws  was  first  advised  by  Dr.  Thomas  L.  Gilmer.^  Dr.  Gilmer  is  a 
strong  advocate  of  this  method,  and  hi.s^good?results  in  large  numbers 
of  difficult  fractures  seems  to  warrant  his  position.     He  says:^ 


1  Arch.  Dent.,  1887,  p,  .388. 


2  International  Congress,  1904,  ii,  185. 


350 


DISEASES  OF  BONE 


"In  cases  of  fracture  of  the  ascending  ramus,  or  at  any  point  posterior 
to  the  third  or  second  molar,  if  most  of  the  teeth  or  a  sufficient  number 
are  in  the  mandible,  the  best  results  are  obtained  by  wiring  the  upper 
teeth  to  the  lower.  This  may  be  done  with  Angle's  bands,  it  is  true, 
but  it  is  not  so  conveniently  done,  I  think,  as  by  wiring  the  upper  teeth 
to  the  lower  teeth.  I  believe  that  this  is  a  better  method  of  treating 
fractures  in  the  angles  or  ascending  ramus  than  by  drilling  through 
the  bone,  unless  there  are  complications. 

"  I  discard  the  use  of  bandages  because  that  may  interfere  with  the 
circulation  and  retard  recovery." 

He  uses  a  small,  very  soft  annealed  German  silver  wire. 


Fig.  178. 


-Cap  splint  or  single  arch  splint  used  whenever  there  are  one  or  more  sound 
teeth  on  either  side  of  the  line  of  fracture.     (Dunning.) 


The  objection  to  fixation  of  the  parts  in  this  way  is,  that  unless 
carefully  done  there  is  tendency  to  loosen  the  teeth.  This,  however, 
need  not  necessarily  occur,  and  is  a  question  of  technic  rather  than  of 
method.  Nourishment  can  be  taken  with  the  jaws  together  but  not  so 
comfortably  or  so  satisfactorily  as  when  the  mouth  can  be  opened. 
Moreover,  the  opportunity  to  view  the  inside  of  the  mouth,  which  is 
prevented,  is  also  important.  It  is  therefore  advisable  to  wire  the 
teeth  together  only  when  more  accurate  results  can  thus  be  secured 
than  by  other  forms  of  dental  or  interdental  splint. 

It  is  very  natural  that  there  should  be  some  question  as  to  priority 
of  invention  or  application  in  the  use  of  methods  such  as  Angle's  for 
fixation  of  fractured  jaws.  But  there  can  be  no  doubt  of  the  fact  that 
Angle,  with  his  well-known  ability  to  bring  to  perfection  any  appliance 


FRACTURES  OF  THE  JAWS 


351 


which  he  clevises  or  employs,  has  done  more  than  anyone  else  toward 
making  treatment  of  fractured  jaws  simple  and  etfecti\'e.  The  follow- 
ing illustrations  of  Angle's  methods  (Figs.  179,  180  and  181)  are  given 


Fig.   179. — Splint  for  fractured  lower  jaw.     (After  Angle.) 


Fig.   180. — Splint  for  fractured  lower  jaw.     (After  Angle.) 


Fig.  181. — Splint  for  fractured  lower  jaw.     (After  Angle.) 

with  full  credit  to  the  author  and  without  prejudice  to  any  others 
who  may  have  previously  employed  similar  but  almost  certainly 
less  perfect  appliances.     Naturally,  in  the  course  of  extended  practice, 


352 


DISEASES  OF  BONE 


whatever  the  original  suggestions  may  have  been,  one  finds  one's  self 
making  certain  modifications  which  appear  to  be  improvements.     In 


Fig.  182. — Loher's  splint. 


Fig.  18.3. — Illustrates  one  of  the  author's  cases.  The  subject,  a  young  man,  suffered 
severe  cranial  injuries  as  well  as  a  fractured  upper  jaw,  from  a  fall  from  the  roof  of  a  shed. 
His  cerebral  condition  necessarily  claimed  first  attention.  Later  the  splint  was  applied 
with  nuts  and  screws  so  adjusted  to  metal  bands  cemented  to  his  teeth  that  both  fixation 
and  correction  could  be  applied  simultaneously.  He  was  able  to  eat  comfortably  imme- 
diately after  the  spHnt  was  applied. 

this  way  the  author  has  adopted  certain  modifications  of  Angle's 
appliance  which  have  seemed  in  certain  cases  to  be  an  improvement 


FRACTURES  OF  THE  JAWS 


353 


(Figs.  179,  180  and  181).  Fig.  182  shows  Loher's;  Fig.  184,  Sauer's; 
Fig.  185,  Martin's;  and  Fig.  186,  Hammond's  splints.  These  are  selt- 
explanatory. 


Fig.  184. — Sauer's  splint. 


Fig.  185. — Martin's  splint. 


Fig.  186. — Hammond's  splint. 


Dr.  J.  D.  Patterson,  of  Kansas  City,  makes  a  practical  suggestion 
for  the  treatment  of  a  fractured  edentulous  jaw  by  utilizing  the  plate 
that  has  been  worn  by  the  patient  and  adjusting  the  parts  to  fit  the 
form  of  the  plate. 
23 


354 


DISEASES  OF  BONE 


Dr.  Patterson  is  also  entitled  to  credit  for  devising  the  bridge  splint 
attached  to  teeth  upon  each  side  of  the  fracture,  and  used  in  the  first 
instance  to  bridge  across  a  space  caused  by  the  loss  of  a  section  of  the 
lower  jaw  from  gunshot  fracture,  but  adaptable  also  for  use  in  a  similar 
manner  for  resection.     By  the  use  of  this  si)lint  the  parts  are  kept 


Fig.   187. — Gunshot  fracture;  cap  splint  in  position.      (Dunning.)' 

apart  and  securely  in  j)osition  until  such  time  as  intervening  tissue 
may  be  formed  and  great  deformity  avoided.  This  method  has  been 
of  great  service  in  the  present  war. 

He  concludes  his  description  of  the  first  use  of  this  splint  on  a  i)atient, 
the  anterior  part  of  whose  jaw  had  been  destroyed  by  a  shot  from  a 
Winchester  rifle  in  1891,  with  the  following  statement: 


Fig.  188.- 


-Shape  of  splint  before  being  fitted  to 
chin.     (Roberts.) 


Fig.  189. — Splint  molded  to 
fit  chin.     (Roberts.) 


"Upon  removal  of  the  splint  I  was  delighted  to  find  that  the  bone 
had  reformed  where  it  had  been  entirely  missing,  and  the  sides  were 
firmly  held  in  their  places  without  any  change  during  the  four  days 
when  I  was  remodelling  the  bridge."^ 


•  Fractures  of  the  Maxilla,  Jour.  Amer.  Med.  Assn.,  Jan.  9,  1915. 
2  Western  Dent.  Jour.,  1891,  p.  536. 


FRACTURES  OF  THE  JAWS  355 

External  Dental  Splint. — ^lany  forms  of  splints  to  be  applied  u])on 
the  outside  of  the  face  and  chin  have  been  devised.  These  are  equally 
unnecessary  and  are  occasionally  required.  The  splints  illustrated 
in  Figs.  ISS  and  ISO  are  an  example  of  splints  of  this  character  which 
are  valuable  because  of  their  simple  construction. 

In  fracture  through  the  angle  of  an  edentulous  lower  jaw  it  is  some- 
times necessary  to  hold  the  ramus  forward  against  the  body  of  the 
mandible,  and  wiring  the  bones  may  sometimes  be  avoided  by  molding 
modelling  compound  to  fit  closely  around  the  angle  of  the  jaw  upon 
the  external  surface  and  by  binding  this  into  place  with  a  bandage 
having  a  few  layers  of  cotton  under  it  to  protect  the  skin. 

Dr.  F.  A.  Green,  of  Geneva,  Xew  York,  has  devised  an  appliance 
which  combines  an  external  dental  splint  uith  an  interdental  one.  Its 
purpose  is  to  give  both  external  and  internal  fixation  to  the  lower  jaw 
without  the  use  of  bandages.  Description  of  this  splint  with  illustra- 
tion is  published  in  the  International  Congress,  1904,  ii,  183,  1S4. 

Bands  or  wires  ■sxhich  are  to  be  depended  upon  for  securing  fractm-ed 
jaws  should  not  be  attached  to  the  teeth  immediately  upon  each  side 
of  the  fracture,  because  as  a  result  of  the  traumatism  or  subsequent 
infiammation  such  teeth  are  always  loosened.  Attachment  should 
be  made  to  teeth  two  and  sometimes  three  teeth  a^  ay  from  the  line  of 
bone  di\'ision. 

J]'iring  fractured  ends  of  jnaxillari/  bones  is  occasionally  necessary 
when  approximation  and  immobility  cannot  otherwise  be  secured. 
but  this  method  should  be  avoided  if  possible,  because  opening  through 
the  tissues  and  bone  for  insertion  of  the  wires  gives  exposure  to  infec- 
tion, and  with  the  wires  in  place  this  disadvantage  is  continued. 
Incision  made  through  the  external  surface  of  the  face  to  expose  the 
bone  for  the  purpose  of  inserting  wu'e  gives  still  greater  opportunity 
for  infection  and  makes  an  unnecessary,  often  unsightly  scar.  It  is 
practically  impossible  to  pass  silver  wire  as  generally  used  through 
the  jaw  bones  and  twist  the  ends  with  sufficient  accuracy  to  give 
perfect  immobility;  consequently  there  is  usually  more  or  less  motion 
in  segments  of  the  jaw  thus  attached.  Sometimes  this  is  of  little  eon- 
sequence,  and  union  takes  place  apparently  without  interruption,  but 
in  many  instances  it  has  led  to  delayed  or  faulty  union  as  well  as 
deformity  through  disarrangement  of  the  parts. 

In  this  connection  it  must  be  remembered,  however,  that  there  are 
eases  in  which  suturing  of  the  fractm-ed  bones  cannot  be  avoided, 
because  no  splint  serves  the  purpose  as  well.  Fortunately  these  cases 
are  rare,  and  almost  always  a  dental  or  interdental  splint  can  be  used  to 
better  advantage. 

The  bandages  generally  used  for  detention  of  fractures  of  the  jaws  are 
illustrated  in  Figs.  190  to  193. 

Of  these  the  most  commonly  used  is  the  Barton  bandage.  The  four- 
tailed  bandage  is  made  by  splitting  a  three-inch  roll  of  bandage  from 
each  end  to  a  point  within  two  or  three  inches  from  the  center.  The 
free  ends  are  then  applied  as  sho"^Ti  in  Fig.  190. 


356 


DISEASES  OF  BONE 


Patients  in  whom  a  bandage  such  as  the  Barton,  which  holds  the 
jaws  firmly  together,  had  been  apphed  while  under  influence  of  an 
anesthetic,  must  be  very  carefully  watched  and  the  nurse  or  attendant 


Fig.  190. — Four-tailed  bandage  of  chin. 
(Wharton.) 


Fig.  191. — Barton's  bandage. 
(Wharton.) 


Fig.   192. — Modified  Barton's  bandage. 

(Wharton.) 


Fig.   193. — Obhque  bandage  of  the  angle 
of  the  jaw.     (Wharton.) 


instructed  to  cut  the  bandage  instantly  in  cases  of  vomiting  which 
otherwise  might  lead  to  suffocation.  Quite  serious  accidents  of  this 
nature  have  been  reported.  Usuall}^  the  application  of  such  bandages 
during  anesthesia  may  be  avoided,  and  when  this  is  impossible  the  like- 


FRACTURES  OF  THE  JAWS  357 

lihood  of  danger  will  be  reduced  when  opportunity  is  given  for  proper 
preparation  of  the  patient  before  operation  and  the  postoperative 
hypodermic  injections  of  morphin.  But  in  no  case  should  vigilance  be 
relaxed  until  the  period  of  danger  is  over. 

Cases  in  which  habitual  drunkenness  or  other  reasons  make  it 
impossible  to  keep  the  patient's  bandages  in  place  have  been  reported 
by  Roe,  Marshall,  and  others.  In  these  the  difficulty  can  be  overcome 
by  shaving  the  head  and  attaching  broad  strips  of  adhesive  plaster 
or  a  cap  of  metal  or  other  material,  which  may  be  adjusted  to  the  head 
and  the  adhesive  strips  attached  without  the  necessity  of  shaving  the 
head. 

It  is  unnecessary  to  describe  the  manufacture  of  interdental  splints, 
which  is  understood  by  all  dentists  and  fully  described  in  works 
upon  prosthetic  dentistry.  It  seems  advisable,  however,  to  call 
attention  to  the  fact  that  it  is  often  difficult  and  sometimes  quite 
impossible  to  §ecure  a  correct  impression  of  a  fractured  jaw.  This 
can  be  overcome  by  the  method  of  sawing  through  the  plaster  case 
secured  from  such  an  impression  at  the  line  of  fracture  and  adjusting 
the  teeth  to  correct  occlusion  with  a  cast  made  of  an  impression  of  the 
opposite  jaw.  In  this  way  an  imperfect  impression  may  be  converted 
into  a  sufficiently  perfect  one,  providing  the  dental  arches  were  origi- 
nally reasonably  regular  in  outline. 

Once  the  parts  have  been  firmly  secured,  the  treatment  is  the  same 
as  for  other  wounds.  With  compound  fractures,  care  must  be  exercised 
to  avoid  or  overcome  the  results  of  infection.  Harmless,  sufficiently 
antiseptic  mouth  washes  should  be  used  frequently,  wound  surfaces, 
if  accessible,  painted  occasionally  with  tincture  of  iodin,  and  close 
observation  given  to  detect,  and,  if  necessary,  to  relieve,  formation 
of  pus  to  prevent  necrosis  if  possible.  When,  by  reason  of  comminu- 
tion of  the  parts  or  otherwise,  sequestra  of  bone  require  removal,  this 
should  be  done  in  the  same  manner  as  in  other  forms  of  necrosis. 
Nourishment  ought  to  be  suited  to  the  conditions  under  which  it  must 
be  taken  and  as  highly  nutritive  as  possible.  The  bowels  must  be  kept 
open  and  generally  healthful  conditions  must  be  observed. 

Repair  of  Fracture. — When  a  fracture  is  properly  set  the  resulting 
hyperemia  is  followed  by  the  exudation  of  lymph  which  solidifies 
around  the  broken  fragments  and  encloses  the  blood  clot  and  perios- 
teum together  with  such  other  tissues  as  may  have  been  displaced 
by  the  traumatism.  This  becomes  vascularized  and  forms  the  fibrous 
tissue  of  the  provisional  callus  during  the  first  week,  which  eventually 
becomes  calcified  and  forms  the  permanent  callus.  The  latter  ensheaths 
the  bone  at  points  of  fracture  and  serves  to  give  necessary  protection 
until  union  may  take  place  by  more  than  normal  development.  In 
the  course  of  time  the  callus  is  absorbed  and  disappears  almost  entirely, 
but  a  slight  thickening  along  the  line  of  fracture  usually  remains. 

Length  of  Time  Required  for  Complete  Union. — The  period  during 
which  it  is  necessary  to  continue  fixation  of  fractured  bones  depends: 


358  -  DISEASES  OF  BONE 

(1)  Upon  the  situation  of  the  fracture,  which  is  exposed  or  subject 
to  the  action  of  powerful  muscles,  requires  a  longer  time  for  healing 
than  when  such  adverse  conditions  are  not  operative;  (2)  upon  unfavor- 
able constitutional  conditions  such  as  debility  from  old  age,  long-con- 
tinued fevers,  pregnancy,  prolonged  lactation,  scorbutus,  tuberculosis, 
syphilis,  rickets,  etc. ;  (3)  upon  mobility  due  to  imperfect  approximation 
of  the  parts  or  insecure  fixation,  and  complications  such  as  the  inter- 
position of  foreign  substances,  soft  tissues  of  the  mouth,  displaced 
teeth,  suppuration,  necrosis,  etc. 

The  time  required  for  union  to  take  place  may  vary  from  two  weeks 
and  a  half,  an  unusually  short  time,  to  several  months.  Ordinarily 
five  or  six  weeks  are  required  to  give  a  reasonably  good  result.  But 
the  judgment  of  the  operator  must  recognize  adverse  conditions,  and 
in  these  cases  allow  the  retention  appliance  to  remain  in  position  a 
sufficient  time  to  make  the  united  fragments  self-sustaining. 

Delayed  Union. — Delayed  union  may  persist  for  months,  and  yet, 
with  improvement  of  the  adverse  constitutional  or  other  condition, 
union  may  take  place  in  natural  course. 

Faulty  Union. — Under  unfavorable  conditions  there  may  be  no  per- 
ceptible eflfort  at  repair,  or  fibrous  union  may  occur  by  the  formation  of 
fibrous  tissue  between  the  ends  of  the  bone  fragments,  which  through 
absorption  and  rounding  of  angular  surfaces  by  more  or  less  continued 
motion  sometimes  results  in  a  false  joint  (pseudarthrosis) . 

In  the  treatment  of  united  fracture  of  this  character  it  is  necessary 
to  remove  the  intervening  fibrous  tissue  and  to  freshen  the  bone  bor- 
ders, then  they  must  be  brought  into  contact  and  held  securely  with 
a  suitable  splint  or  by  wiring,  as  in  the  case  of  recent  fractures.  Patho- 
logical constitutional  states  should  receive  appropriate  treatment  to 
favor  the  process  of  bone  repair. 

Attempts  to  hold  jaw  fractures  by  ligatures  or  wires  around  the 
teeth  immediately  upon  each  side  of  the  fracture  without  other  sup- 
porting assistance  are  almost  always  ineffective,  and  should  not  be 
depended  upon  as  a  matter  of  general  practice.  Constant  movement, 
because  of  imperfect  fixation,  is  the  chief  cause  of  both  delayed  and 
faulty  union. 

Complications  of  Fracture. — The  trauma  which  caused  the  bone 
lesion  may  result  in  serious  injury  to  other  parts,  or  the  bone  fragments 
may  be  forced  into  or  against  important  structures  and  cause  laceration 
of  important  vessels,  with  profuse  and  even  dangerous  hemorrhage. 
Pressure  upon  a  nerve  trunk  may  cause  numbness  or  paralysis.  Viru- 
lent forms  of  infection  may  be  carried  into  the  wound  at  the  time  of 
injury  and  result  in  tetanus,  septicemia,  or  other  infectious  diseases. 
Double  fracture  of  the  anterior  part  of  the  lower  jaw  by  action  of  the 
digastric,  the  mylohyoid,  and  geniohyoglossus  muscles  allows  the  part 
to  drop  downward  and  baclnvard  with  consequent  difficult  breathing 
or  even  suffocation.  Drawing  the  tongue  forward  in  these  cases  is  not 
sufficient.     Stiffness  of  the  jaw  through  injury  of  the  glenoid  cavity 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    359 

or  fixation  for  a  long  period  of  time  may  lead  to  complete  or  partial 
ankylosis.  Necrosis  from  infection  or  comminuted  fragments  of  bone 
often  delay  union,  and  may  cause  septicemia  or  pyeviia  with  quite 
serious  general  results. 

The  most  frequently  troublesome  complication,  and  one  which  is 
peculiar  to  the  jaws  and  not  found  in  any  other  form  of  fracture,  con- 
sists in  abscess  and  continuance  of  suppuration  from  teeth  devitalized 
by  the  traumatism  which  caused  the  fracture.  These  teeth  are  often 
quite  sound,  and  if  not  noticeably  displaced  give  no  outward  sign  of 
being  affected,  and  yet,  over  and  over  again  in  the  author's  practice, 
it  has  happened  that  healing  processes  have  been  delayed  or  union 
prevented  by  this  simple  cause.  Pus  from  the  roots  of  these  teeth 
in  which  the  pulps  have  become  gangrenous  follows  the  line  of  fracture, 
and  no  matter  what  may  l>e  done  in  the  way  of  other  treatments,  the 
discharge  of  pus  with  corresponding  destruction  of  bone  will  be  con- 
tinued almost  indefinitely.  Such  teeth  should  be  suspected  at  once 
and  always  sought  for  in  every  case  of  faulty  union. 

Fractures  of  the  upper  jaw  very  frequently  involve  the  maxillary 
sinus,  and  when  compound  or  comminuted,  one  or  both  antra  may 
become  infected.  If  there  be  no  other  cause  for  continuance  of  antral 
disease  such  conditions  clear  up  in  the  course  of  time,  and  unless 
necrosis  of  the  bony  walls  occurs  they  are  not  usually  followed  by 
chronic  empyema. 


AFFECTIONS  OF  THE  TEMPOROMANDIBULAR 
ARTICULATION 

Description. — In  the  temporomandibular  articulation  the  socket  is 
formed  partly  by  the  mandibular  fossa  and  partly  by  the  articular 
eminence,  and  over  the  latter  an  approximately  confluent  surface 
for  the  head  of  the  condyle  is  formed  by  the  articular  disk.  The  two 
temporomandibular  articulations  act  simultaneously. 

When  the  mouth  is  opened  the  head  of  the  condyle  with  the  inter- 
articular  disk  glides  forward  upon  the  articular  eminence,  and  when 
the  mouth  is  closed  it  slips  back  into  the  mandibular  fossa.  The  open- 
ing and  closing  of  the  mouth  are  consequently  attended  by  a  sliding  of 
the  mandible  (a  gliding  jointj. 

In  addition  to  this  modified  form  of  hinge  movement,  the  articu- 
lation possesses  a  second  kind  of  motion,  the  lateral  displacement  of 
the  mandible  in  reference  to  the  skull.  In  this  movement  one  con- 
dyloid head  remains  in  the  mandibular  fossa,  while  the  other  advances 
upon  the  articular  eminence,  a  movement  which  is  impossible  when 
the  mouth  is  opened  to  its  greatest  extent.  Both  the  hinge  and  the 
lateral  movements  are  combined  in  the  act  of  mastication.^ 

1  Sobotta-McMurrich :  Atlas  and  Text-book  of  Human  Anatomy,  i,  118. 


360  DISEASES  OF  BONE 

Alterations  in  Form. — As  the  result  of  jaw  habits  the  complete  or 
partial  loss  of  teeth,  irregularity  of  teeth  and  other  deformities  of 
the  maxillae,  abnormal  movement  of  the  mandible  results.  These, 
the  author  believes,  often  have  pathological  importance.  When  the 
anterior  portion  of  the  alveolar  ridges  is  allowed  to  come  in  close  con- 
tact there  is  more  or  less  disarrangement  in  the  relative  situations  of 
the  condyles,  the  intra-articular  cartilages,  and  the  coronoid  processes. 
In  this  way  pressure  upon  nerve  trunks  is  sometimes  occasioned  and 
may  become  an  active  factor  in  the  causation  of  persistent  pain  in  the 
distribution  of  the  fifth  nerve.  When  from  habit  or  necessity  there  is 
unusual  sliding  backward  or  forward  of  the  mandible  or  continued 
lateral  movement  the  result  as  might  be  expected  is  bone  absorption 
through  which  there  is  enlargement  of  the  mandibular  fossa.  Sometimes 
this  is  evidenced  by  more  or  less  reduction  of  the  eminentia  articularis 
and  occasionally  bj'  absorption  of  the  posterior  wall  of  the  fossa.  In 
one  of  the  author's  cases  this  was  very  marked  through  abrasion  of  the 
anterior  teeth  and  consequent  tipping  of  the  anterior  part  of  the  man- 
dible upward  and  forward  and  tipping  of  the  condyloid  processes 
upward  and  backward.  Constantly  applied,  more  than  ordinarily 
powerful  muscles  of  mastication  exercised  in  the  habit  of  clinching 
the  teeth  together  caused  the  heads  of  both  condyles  to  work  backward 
and  upward.  This  led  to  extensive  absorption  of  the  anterior  bony  wall 
of  the  external  auditory  meatus  and  compression  of  the  openings  of 
both  external  auditory  meatuses  during  closure  of  the  jaws  with 
attendant  more  or  less  perceptible  deafness.  When  the  jaw  was  relaxed 
or  the  mouth  partly  opened,  the  deafness  was  relieved.  Changes  in 
the  form  of  the  mandibular  fossa  and  in  the  heads  of  the  articular 
surfaces  of  the  condyles  bear  an  important  relation  to  diseases  of  the 
teeth  and  pericementum,  particularly  interstitial  gingi^'itis  or  that 
form  which  is  known  as  pyorrhea  alveolaris.  It  also  accounts  for  much 
of  the  difficulty  experienced  with  artificial  dentures.  This  form  of 
enlargement  of  the  temporomandibular  fossa,  especially  when  associ- 
ated with  loss  of  distinct  form  and  particularly  changed  outline  of  the 
eminentia  articularis,  accompanied  by  the  general  laxity  of  ligamen- 
tous and  muscular  attachments  which  is  naturally  acquired  under  these 
conditions,  favors  dislocation  of  the  mandible  in  certain  individuals. 
There  is  unlimited  clinical  evidence  that  such  alterations  in  the  form 
and  structure  of  the  parts  associated  in  the  temporomandibular  articu- 
lation do  occur.  Cryer,  through  his  anatomical  studies  of  dried  speci- 
mens, has  added  the  final  proof  by  calling  attention  to  the  more  or  less 
frequent  evidences  of  absorption  that  he  has  found  in  both  the  condy- 
loid processes  and  the  mandibular  fossse. 

Dislocation. — Definition. — Dislocation  or  luxation  is  defined  as  dis- 
placement of  bones  at  a  joint  or  an  organ  from  its  usual  situation. 

In  the  surgical  sense  the  term  dislocation  is  used  to  describe  the 
separation  of  the  articular  surfaces  of  two  or  more  bones  entering  into 
the  formation  of  a  joint. 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    361 


Classification.— 

Traumaiic. — When    caused    by    injury. 


Spontaneous. — Any  dislocation  not 
caused  by  external  violence  (usually 
pathological) . 

Complete. — When  the  articular  surfaces 
are  entirely  separated. 

Simple. — When  covered  by  unbroken 
tissues. 

Complicated. — When  accompanied  by 
serious  injury  to  surrounding  parts,  such 
as  important  vessels  or  nerves,  injury  to 
the  capsvile,  or  fracture  of  the  bones  at  the 
joint. 

Primitive. — -When  the  articular  surfaces 
retain  their  first  position  after  luxation. 


Recent. 
Single. - 


-When  there  is  one  dislocation. 


Unilateral. — ^When  a  bone  situated  in 
such  po.sition  in  the  body  as  to  have  an 
articular  surface  upon  each  side  is  dislo- 
cated upon  one  side. 


Pathological. — When  brought  about 
by  disease  resulting  in  destruction  of 
tissues  of  the  joint  and  displacement  by 
muscular  action. 

Congenital. — If  resulting  from  prenatal 
defect  or  malformation.  This  form  of 
dislocation  is  rare  and  must  not  be  con- 
founded with  injury  during  delivery. 

Incomplete. — ^When  only  partly  sepa- 
rated and  some  point  of  contact  remains. 

Compound. — With  an  external  wound 
leading  to  the  joint  cavity. 

Relapsing. — When  recurring  after  a 
previous  dislocation,  either  because  of 
insufficient  time  for  repair  of  the  parts 
or  through  chronic  relaxation  of  the  liga- 
ments. 

Consecutive. — When  still  further  move- 
ment allows  a  new  position  of  the  articu- 
lar ends  of  the  bones. 

Aiicient. 

Double. — When  there  is  luxation  of  the 
same  joint  in  both  of  two  similar  bones 
upon  each  side  of  the  body. 

Bilateral. — -When  a  bone  having  artic- 
ular surfaces  upon  each  side  of  the  body 
is  luxated  on  both  sides.  Examples  of 
these  bones  are  the  inferior  maxillge,  the 
sternum,  and  the  hyoid  bone. 

Dislocations  of  the  lower  jaw  are  usually  intracapsular  because  of  the 
wide  articular  capsule  permitting  dislocation  without  division  of  its 
surface,  and  therefore  simple  dislocation  is  the  most  common  form, 
although  both  compound  and  complicated  dislocations  sometimes  occur 
from  severe  injuries. 

Incomplete  Dislocatio?!.— Through  relaxed  conditions,  one  or  both 
condyles  may  lodge  upon  the  intra-articular  cartilage  over  the  emi- 
nentia  articularis. 

Unilateral  dislocation  describes  displacement  upon  one  side  only. 
The  dislocation  is  bilateral  when  it  occurs  upon  both  sides. 

Fonvard  dislocation  is  the  typical  form  of  dislocation  of  the  lower 
jaw.  But  in  rare  instances  there  is  backward  dislocation,  in  which 
the  articular  process  glides  over  the  small  t;>Tnpanic  tubercle  which 
closes  the  articular  fossa  behind  and  reaches  the  tympanico stylomastoid 
fossa^ 

Etiology. — If  for  any  reason  the  head  of  the  condyle  when  the  mouth 
is  opened  passes  over  the  eminentia  articularis  to  a  point  beyond  that 
from  which  it  can  glide  backward  with  normal  movement  in  closure  of 
the  jaw,  it  may  become  fixed  in  this  position  or  slide  forward  over  and 
beyond  the  articular  eminence,  to  be  drawn  upward  and  forward  in 
fixed  position  by  contraction  of  the  masseter  and  temporal  muscles  and 
stretching  of  the  sphenomaxillary  and  stylomaxillary  ligaments.     This 


1  Described  by  Schlatter,  von  Bergmann's  System  of  Practical  Surgery,  i,  672. 


362  '  DISEASES  OF  BONE 

is  a  typical  form  of  dislocation  of  the  lower  jaw.  Abnormality  in  the 
form  of  the  mandibular  fossa  with  unusual  muscular  and  ligamentous 
relaxation  to  which  reference  has  already  been  made,  would  be  termed 
predisposing  causes. 

The  jaws  of  children  are  less  frequently  dislocated  than  adults, 
because  the  eminentia  articularis  is  not  so  marked  and  the  angles  of 
the  rami  are  obtuse.  On  the  other  hand,  dislocation  among  women 
is  much  more  frequent  than  among  men  (according  to  Kronlein  four 
times  more  frequent),  because  of  the  shallower  development  of  the 
articulation  and  the  greater  tendency  to  conditions  of  general  health, 
which  predispose  to  muscular  relaxation  and  the  greater  tendency  to 
nervous  jaw  habits,  which  lead  to  pathological  changes  in  the  fossa. 

Direct  causes  are  usually  immoderate  opening  of  the  mouth,  such 
as  in  yawning,  laughing,  states  of  excitement,  screaming,  vomiting, 
the  insertion  of  mouth  gags,  stretching  the  mouth  open  for  the  purpose 
of  performing  dental  operations  of  various  kinds,  violence,  blows  upon 
the  side  of  the  face,  which  usually  lead  to  unilateral  dislocation,  or 
upon  the  chin  with  the  mouth  open,  which  by  driving  it  backward  and 
downward  cause  bilateral  dislocation. 

Backward  dislocation  is  caused,  according  to  Thiem,i  by  forcibly 
closing  the  teeth,  the  action  of  the  temporal  muscle  forcing  the  jaw 
backward.  Doubtless  this  would  be  favored  by  traumatic  force  at 
the  point  of  the  chin  with  the  jaw  closed. 

Pathology. — ^When  the  joint  capsule  is  relaxed  or  the  surrounding 
muscles  and  ligaments  have  lost  their  activity,  through  paralysis  or 
otherwise,  dislocation  may  take  place  without  laceration  of  the  synovial 
membrane.  When,  however,  dislocation  occurs  under  normal  condi- 
tions from  some  unusual  force,  there  may  not  only  be  laceration  of  the 
capsule,  but  involvement  of  the  surrounding  and  associated  bone 
and  soft  tissues.  Hemorrhage  and  inflammatory  conditions  naturally 
follow  with  resulting  exudate  and  the  formation  of  connective  tissue, 
which  in  reduced  dislocations  in  the  course  of  time  render  their  reduc- 
tion exceedingly  difficult  or  impossible.  Through  infection  the  integ- 
rity of  the  glenoid  cavity  or  the  condyloid  processes  may  be  more  or 
less  completely  destroyed  by  suppurative  processes. 

Symptoms.— Forward  dislocation  of  the  mandible  gives  a  general 
picture  of  distress,  but  the  explanation  of  the  symptoms  is  obvious 
(Fig.  194). 

In  bilateral  forward  dislocation  the  mouth  is  widely  opened;  with  the 
lower  jaw  fixed  in  this  position,  the  loiver  teeth  project  beyond  the  line 
of  the  upper,  there  is  abnormal  floio  of  saliva,  and  a  distinct  depression 
at  the  glenoid  cavity,  in  front  of  the  tragus;  the  head  of  the  condyle  can 
be  felt  beneath  the  malar  bone,  and  the  coronoid  processes  felt  from 
within  the  mouth  are  found  to  be  displaced  forward  under  the  zygoma. 
Marked  muscular  contraction  may  be  accompanied  by  paiii.    The 

1  Von  Bergmann's  Bulletin,  p.  672. 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION     3G3 

fixed  position  of  the  jaw  interferes  with  speech  and  prevents  use  of  the 
jaws  in  mastication  or  otherwise.  Unilateral  dislocation  is  marked  by 
similar  symptoms  upon  one  side  only  with  the  chin  displaced  toward 
the  unaffected  side. 

As  previously  noted,  this  is  distinguished  from  unilateral  fracture 
of  the  neck  of  the  condyle,  because  in  this  form  of  fracture  the  chin 
and  jaw  are  pulled  toward  the  injured  side.  In  the  course  of  time  pain 
ceases  to  be  troublesome,  and  if  the  dislocation  is  not  reduced  a  certain 
amount  of  free  movement  is  acquired  through  loosening  of  the  capsule. 
In  backward  dislocation  the  teeth  of  the  lower  jaw  rest  behind  those 
of  the  upper,  and  the  condyloid  process  can  be  felt  beneath  the  external 
auditory  meatus  in  front  of  the  mastoid  process. 


Fig.  194. — Bilateral  dislocation  of  the  lower  jaw.     (Hamilton.) 


Diagnosis. — The  symptoms  as  described  are  in  most  cases  recog- 
nized without  difficulty.  Confusion  could  only  occur  through  some 
complicating  condition  or  in  backward  dislocation,  and  in  cases  of  this 
character  the  x-rays  are  a  valuable  aid  in  determining  the  exact  situa- 
tion of  the  parts. 

Treatment. — ^To  make  reduction  of  a  dislocated  lower  jaw,  stand 
in  front  of  the  seated  patient,  and,  with  thumbs  well  wrapped  for 
protection,  placed  upon  the  lower  molar  teeth  upon  each  side  of  the 
dislocated  jaw,  make  pressure  downward  and  slightly  backward,  at 
the  same  time  lifting  the  chin  upward  with  the  other  fingers.  In 
more  obstinate  cases  pieces  of  wood  or  cork  may  be  placed  between 


364  DISEASES  OF  BONE 

the  molar  teeth,  and  standing  behind  the  patient,  whose  head  rests 
against  the  operator's  chest,  with  hands  clasped  under  the  chin,  force 
is  exerted  to  draw  it  upward.  It  is  sometimes  necessary  to  give  a 
general  anesthetic  to  cause  muscular  relaxation.  In  irreducible  or 
chronic  cases  the  removal  of  the  coronoid  processes  or  operations  upon 
ligaments  have  been  recommended,  but  conditions  calling  for  such 
radical  treatment  are  exceedingly  rare,  and  the  results  undoubtedly 
more  or  less  uncertain.  In  unilateral  dislocation  the  treatment  above 
described  is  applied  to  the  affected  side  and  simultaneously  an  addi- 
tional effort  to  force  the  chin  toward  the  median  line.  Backward 
dislocations  are  reduced  by  forcibly  opening  the  mouth  or  by  pressing 
the  lower  jaw  backward,  then  downward  and  for^vard,  under  anesthesia. 
The  after-treatment  in  all  forms  of  dislocation  of  the  mandible  is  to 
limit  or  control  its  movement,  to  prevent  tendency  to  recurrence  until 
after  the  parts  have  had  opportunity  to  reco\-er.  Usually  this  requires 
ten  days  and  sometimes  longer.  Food  should  therefore  be  such  as  to 
require  slight  movement  of  the  jaw,  if  any,  and  highly  nourishing  in 
character.  Recurrent  dislocations  are  often  very  troublesome  (Fig. 
195). 


Fig.  195. — Reduction  of  dislocation  of  lower  jaw. 

Chronic  Dislocation  of  the  Jaw. — C.  Riley ^  reports  the  case  of  a 
young  woman  whose  jaw  became  constantly  dislocated  when  talking 
and  laughing  after  having  been  dislocated  for  the  first  time  in  a  den- 
tist's chair.  She  was  relieved  by  an  appliance  which  is  illustrated 
(Fig.  196).     It  is  described  as  follows: 

"A  piece  of  German  silver  wire  was  bent  so  as  to  fit  across  the  top 
and  sides  of  the  head  and  extend  down  toward  the  zygoma  and  over 
the  joint  on  each  side.  On  the  inner  side  of  each  end  there  was  riveted 
a  plate  about  three-quarters  inch  in  diameter,  which  was  padded 
with  piano  felt  and  covered  with  kid.  The  Avire  was  bent  so  as  to  make 
firm  pressure  over  and  slightly  below  the  joints.  This  acted  in  retain- 
ing reduction,  enabled  her  to  eat  solid  food  in  a  short  time,  and  ulti- 
mately to  do  away  with  the  apparatus." 

1  Am.  Jour.  Orthop.  Siirg.,  April,  1908. 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    365 

Iviyerjed  dislocation  or  subluxation  of  the  loicer  jaw  Marshall  de- 
scribes as  a  condition  in  which  the  condyle  partially  slips  from  the 
glenoid  fossa  in  a  forward  direction,  and  in  front  of  the  interarticular 
cartilage,  when  the  mouth  is  opened.  Upon  closing  the  mouth  the 
condyle  goes  back  again  to  its  place  with  a  clicking,  snapping  sound. 
Sometimes  it  catches  for  a  moment  when  the  mouth  is  widely  extended 
and  causes  anxiety  on  the  part  of  the  patient  for  fear  that  the  jaw  is 
dislocated. 

Pathology. — The  pathology  consists  in  alterations  of  the  mandibular 
fossa  and  relaxation  of  the  surrounding  ligaments  as  previously 
described. 


Fig.  196. — Riley's  appliance  for  chronic  dislocation  of  the  lower  jaw. 

Treatment. — No  treatmient  is  required  except  in  rare  instances 
when  reduction  cannot  be  accomplished  by  the  patient  without  assist- 
ance. If  very  annoying,  temporary  fixation  of  the  parts  may  assist 
in  stiffening  the  parts  surrounding  the  articulation  and  decrease  the 
likelihood  of  its  recurrence. 

Arthritis. — The  temporomandibular  articulation  is  subject  to  the 
same  inflammatory  affections  as  other  joints.  Inflammations  limited 
to  distinct  parts  are  described  as  chondritis,  when  affecting  the  cartil- 
age; synovitis,  the  synovial  membrane;  parasynovitis,  the  joint  capsule 
and  ligaments;  and  panarthrosis  when  all  parts  are  involved. 

These  terms  are  of  little  clinical  value,  because  in  acute  inflamma- 
tions almost  invariably  all  of  these  structures  are  involved  together. 
In  rare  instances,  however,  some  one  of  them  may  be  affected  by  a 
low-grade  chronic  inflammation  without  necessarily  involving  the  asso- 
ciated parts.  Surgical  affections  usually  begin  in  the  synovial  sac  as 
synovitis. 

The  temporomandibular  articulation  is  not  as  frequently  exposed 


1  Injuries  and  Surgical  Diseases  of  the  Face,  p.  254. 


366  DISEASES  OF  BONE 

to  traumatic  and  other  injuries  as  many  other  joints  in  the  body,  and 
inflammations  beginning  in  the  joint  cavity  are  comparatively  rare, 
and  further,  because  it  is  the  results  of  such  inflammations  that  the 
surgeon  is  chiefly  called  upon  to  treat.  For  the  sake  of  brevity  and 
practical  advantage  the  pathological  conditions  leading  thereto  will 
be  described  in  relation  to  their  eftect  in  limiting  the  free  movement 
of  the  joint. 

Synovitis. — Classification.— 

Primary.  Secondary. 

Acute.  Chronic. 

Etiology. — Causes  are  traumatic  injuries,  aftections  of  the  s^Tiovial 
membrane  or  articular  cartilages,  foreign  bodies  in  the  joint,  and  inflam- 
matory process  due  to  the  foregoing  causes  or  bacterial  or  chemical 
irritants  in  the  circulation.  The  general  causes  include  diseases  due 
to  faulty  metabolism,  rheumatism,  gout,  and  infectious  diseases,  such 
as  influenza,  pneumonia,  typhoid,  and  scarlet  fevers,  gonorrhea, 
syphilis,  etc.  Neuropathic  influences  manifest  themselves  as  causal 
factors  in  spinal  and  other  nerve  affections. 

Pathology. — The  disease  may  be  monarticular  (affecting  one  joint 
or  polyarticular  (affecting  more  than  one  joint).  Its  first  manifesta- 
tions are  usuall;\'  in  the  syno\ial  membrane.  As  a  result  there  may 
be  a  decrease  of  serous  secretion  with  exudate  having  a  tendency  to 
coagulate — dry  synovitis  (synovitis  sicca).  In  acute  synovitis  there  is 
usually  more  or  less  effusion.  If  this  becomes  infected  it  is  known  as 
purulent  s\iiovitis  and  in  chronic  synovitis  in  the  absence  of  pus  the 
serous  eft'usion  is  called  hydrarthrosis.  Such  effusions  naturally  cause 
distention  of  the  synovial  membrane,  with  such  changes  in  the  struc- 
tures of  the  joint  as  their  character  would  indicate. 

Symptoms. — The  symptoms  consist  in  more  or  less  loss  of  motility, 
pain,  and  swelling.  In  chronic  forms  there  may  be  deformity,  as  in 
arthritis  deformans,  complete  ossification  of  the  joint,  as  in  osteo- 
arthritis, or  the  destructive  processes  of  caries  and  necrosis. 

Treatment. — Treatment  must  be  so  directed  as  to  overcome  the 
cause  and  relieve  the  local  sjmiptoms,  with  a  view  to  prevent  stiffening 
of  the  joint.  With  reference  to  the  lower  jaw  this  is  as  described  in 
treatment  of  temporary  ankylosis,  page  368. 

Ankylosis  of  the  Jaws. — ^Yhile  the  following  classifications  are 
applicable  to  ankylosis  of  the  temporomandibular  articulation  in 
common  with  the  other  joints,  the  following  distinctions  require  special 
consideration  in  this  region : 

Classification. — 

Temporary.  Permanent. 

Fibrous.  Bony  or  true  ankylosis. 

Unilateral.  Bilateral. 

Murph}^^  states  that  ankylosis  is  a  generic  term  and  does  not  repre- 

1  Jour.  Am.  Med.  Assn.,  May  20  and  27,  and  June,  1905. 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    367 


sent  a  pathological  entity.     His   classification  of  ankylosis   and  the 
types  of  arthritis  which  lead  to  ankylosis  are  as  follows: 

Capsular 


Ankylosis,  true 
and  false 


Peri-articular 


Articular 


I  Tendinous. 
Tendovaginal. 
Muscular. 


Synovial. 

Cartilaginous. 

Osseous. 


Arthritis 


(a)   Primary  hematogenous  fibrous  arthritis. 

(6)    Dry  fibrous  arthritis  non-traumatic. 

,  ,    rr.  .  •    nu  ii-  -i-    /  With  fracture  into  the  joint 

(c)    Traumatic  fibrous  arthritis  <  ,!,,.,,       ^  r       ,         /        .      •      v 

(  Without  fracture  (contusion). 

Cryptogenetic. 


(d)    Suppurative 


Hematogenous 


Extension 


Metastatic 
Traumatic. 


f  Typhoid. 
I  Scarlatina. 
I  Pyemia. 
I  Gonorrhea. 


Osteitis 


Tuberculous. 

Osteomyelitic  (infective) 
Peri-arthritis  (phlegmon). 
Panarthritis. 


(e)    Ossifying  arthritis  (primary). 
(/)    Static  adhesive. 


Temporary  Ankylosis. — Etiology.^Temporary  ankylosis  is  due  to 
inflammatory  conditions  of  the  tissues  surrounding  the  temporo- 
mandibular articulation,  which  may  be  in  the  nature  of  an  acute 
synovitis  or  stiffness  and  contracture  of  the  surrounding  muscles, 
spasmodic  muscular  contraction  due  to  direct  irritation  of  the  third 
division  or  of  the  trigeminal  nerve,  which,  however,  must  not  be  con- 
founded with  the  trismus  of  tetanus;  parotitis  or  inflammations  of  other 
glands  in  this  region,  both  salivary  and  lymphatic;  tumors,  traumatic 
injuries,  and  infections  of  any  kind  which  may  affect  the  joint  struc- 
tures or  surrounding  parts  without  creating  permanent  injury. 

Pathology. — The  most  frequent  causes  of  temporary  ankylosis  are 
malposition  and  delayed  eruption  of  the  third  molar  teeth  with  attend- 
ant inflammatory  processes  and  dento-alveolar  abscess  in  the  same 
region.  As  the  mandible  develops,  unless  the  third  molars  are  allowed 
to  progress  upward  in  the  natural  course  of  eruption,  it  quite  fre- 
quently happens,  as  the  growth  of  the  roots  proceeds,  that  the  exten- 
sion finally  reaches  the  inferior  dental  canal.  This  occasions  more  or 
less  direct  pressure  upon  the  third  division  of  the  fifth  nerve,  and  in 
this  way  irritation  may  occur  which  can  be  a  factor  in  causing  mus- 
cular spasm  or  in  leading  to  pain  which  may  give  rise  to  inflammatory 
processes,  especially  when  supplemented  by  infection. 

Dento-alveolar  abscess  and  other  infections,  tumors,  and  swellings 
which  restrict  or  obstruct  jaw  movement  do  not  differ  in  their  patho- 
logical manifestations  from  similar  conditions  in  other  parts. 

The  pathology  of  acute  synovitis  has  already  been  described  (p.  366). 


368  DISEASES  OF  BONE 

Symptoms. — The  s^Tiiptoms  are  usually  those  of  acute  inflam- 
matory conditions  when  the  restricted  movement  of  the  mandible 
appears  to  be  merely  incidental  to  other  troublesome  symptoms. 

Prognosis.- — The  prognosis  in  these  cases  is  good,  providing  relief 
can  be  given  before  permanent  changes  in  the  tissues  have  been  allowed 
to  take  place,  l^sually  the  symptom  of  jaw  stifl'ness  disappears  in  the 
course  of  time,  but  occasionally  efforts  to  open  the  mouth  forcibly  must 
be  continued  for  a  considerable  period  to  prevent  the  formation  of 
adhesions. 

Treatment. — Treatment  consists  of  applications  to  reduce  the  swell- 
ing, removal,  or  prevention  of  local  infection  and  separation  of  the 
jaws  when  necessary  with  mouth  gags  or  movement  otherwise  enforced 
if  possible.  When  impacted  third  molars  are  the  cause,  and  there  is 
infection  in  the  surrounding  and  overlying  gum  and  cheek  tissues, 
good  judgment  must  be  exercised  in  deciding  between  immediate 
removal  of  the  impacted  molar,  through  which  complete  relief  might 
be  expected,  or  palliative  treatment  for  the  control  of  the  acute  infec- 
tious condition  before  exposing  the  individual  to  general  infection  by 
allowing  the  pus  microorganisms  directly  to  enter  vessels  A\hich  must 
be  unavoidably  lacerated  in  removal  of  the  tooth.  A  number  of  deaths 
have  been  reported  from  this  cause.  When  the  presence  of  pus  in 
considerable  quantity  seems  to  indicate  danger  in  this  direction  it  is 
usually  the  part  of  wisdom  to  force  the  mouth  open  with  suitable 
mouth  gags,  even  though  an  anesthetic  may  be  required  on  account 
of  the  acute  pain.  They  should  be  kept  apart  with  corks  between  the 
teeth  so  as  to  permit  proper  cleansing  and  treatment  of  the  inflamed 
tissues  in  the  angle  of  the  jaw. 

When  the  acute  infectious  symptoms  have  sufficiently  subsided, 
removal  of  the  impacted  tooth  may  be  safely  performed.  Even  after 
removal  it  is  sometimes  necessary  to  continue  the  processes  of  more 
or  less  forcible  openings  of  the  jaws  in  order  to  prevent  adhesions  in  and 
around  the  joint  which  might  lead  to  more  or  less  permanent  ankylosis. 
If  there  is  synovitis,  with  marked  evidence  of  efli'usion,  which  necessi- 
tates relief  by  division  of  the  synovial  capsule,  this  should  only  be  done 
as  a  last  resort  and  under  the  most  careful  aseptic  precautions  to  pre- 
vent carrying  the  infection  into  the  joint.  Of  course,  when  pus  has 
already  formed  in  this  situation  its  free  evacuation  is  demanded. 

Fibrous  Ankylosis. — Fibrous,  false,  or  pseudo-ankylosis  as  noted 
by  Park  is  more  properly  a  contracture. 

Etiology. — Fibrous,  or  false,  ankylosis  is  caused  by  the  formation 
of  fibrous  tissue  within  the  joint  intra-articular  or  extra-articular, 
cicatricial  or  fibrous  bands  constricting  the  ligaments  or  muscles 
concerned  in  the  movement  of  the  joint,  and  the  structures  immediately 
surrounding  it.  These  may  be  the  result  of  synovitis  and  arthritis 
due  to  s^'philitic  or  other  destructive  process  following  infectious 
diseases,  extensive  burns,  ulcerative  processes  within  the  mouth,  as 
ulcerative  stomatitis,  necrosis  of  the  jaws,  gangrena  oris,  and  similar 
affections. 


AFFECTIONS  OF  TEMPOROMAXDIBULAR  ARTICULATIOX    369 

Pathology. — Intra-articular  adhesions  are  the  result  of  s^Tiovitis  and 
arthritis  in  which  the  exudate  has  become  organized  and  has  caused 
the  formation  of  fibrous  tissue  within  the  joint  or  the  formation  of 
osteophytes  which  interfere  with  free  movement.  In  extra-articular 
conditions  the  cicatricial  and  fibrous  bands  are  formed  in  the  course  of 
heahng  of  extensive  injuries,  ulcerations,  and  gangrenous  or  inflam- 
matory processes  which  mechanically  bind  the  parts.  These  may  be 
in  the  ligaments  surrounding  the  joint  or  in  the  muscles  of  mastication 
or  both. 

Symptoms  and  Diagnosis. — The  symptoms  consist  in  fixation  of  the 
jaw,  but  this  is  usually  susceptible  of  slight  motion,  which  serves  to 
distinguish  it  from  true  or  bony  ankylosis,  for  in  such  cases  movement 
is  impossible. 

Arrested  development  of  the  loicer  jaw  with  marked  recession  of  the 
chin  is  a  notable  feature  when  fixation  of  the  jaw  has  occurred  at  an 
early  period  of  ^life.  It  is  not  always  possible  to  determine  whether  the 
ankylosis  is  unilateral  or  bilateral,  but  in  the  author's  experience  the 
center  of  the  chin  being  more  or  less  noticeably  upon  one  side  of 
the  central  facial  line^  indicates  that  the  jaw  has  been  drawn  toward 
the  affected  side  and  that  loss  of  development  has  been  more  marked 
on  that  side.  Therefore  it  is  fair  to  assume  that  the  affection  is  chiefly 
unilateral,  for  it  must  be  remembered  that  although  the  lesion  that 
caused  the  ankylosis  may  originally  have  been  confined  to  the  temporo- 
mandibular articulation  upon  one  side,  fixation  of  the  jaws  during  a 
long  period  of  time  might  be  expected  to  cause  more  or  less  permanent 
impairment  upon  the  opposite  side.  In  aU  of  the  author's  cases,  four 
of  which  are  referred  to  in  the  following  descriptions,  this  simple  diag- 
nostic feature  has  served  to  point  the  way  to  successful  diagnosis. 

Prognosis. — The  prognosis  in  these  cases  depends  entirely  upon  the 
successful  continuance  of  the  effort  to  keep  the  jaws  open.  The  con- 
traction of  scar  tissue  following  such  operations  continues  for  a  \'ery 
long  period  of  time,  and  it  is  not  stifficient  to  continue  extension  during 
the  healing  of  the  wound  only.  The  muscles  must  be  stretched  by 
forcing  the  jaws  open,  and  this  treatment  continued  for  a  period  of 
time  sufficiently  long  to  make  certain  the  permanency  of  the  results. 

Treatment. — ^Yhen  the  fibers  or  cicatricial  bands  which  hold  the  jaw 
in  fixed  position  are  confined  to  one  side  and  are  so  situated  that  anky- 
losis would  persist  exen  though  the  jaw  were  free  at  the  articulation. 

Such  cases  may  be  treated  by  severing  the  restricting  bands  of  tissue 
from  within  the  mouth;  continued  separation  of  the  jaws  by  the  use 
of  a  mouth  gag  until  the  necessary  freedom  of  movement  has  been 
secured;  continuance  of  this  movement  and  prevention  of  reformation 
of  the  adhesive-tissue  bands  and  contracting  muscular  factors  by 
keeping  the  mouth  permanently  and  continuously  open  and  the  jaw 
in  free  movement  until  there  appears  to  be  no  likelihood  of  recurrence 

1  An  imaginary  line,  referred  to  elsewhere,  taken  from  the  central  portion  of  the  fore- 
bead  perpendiciilarly  down  through  nose  and  chin. 
24 


370 


DISEASES  OF  BONE 


of  fixation.  The  author  has  had  many  satisfactory  results  in  the 
treatment  of  unilateral  fibrous  ankylosis  by  the  intra-oral  operation 
as  described  in  the  following  cases  from  his  own  practice. 

The  history  of  such  treatment  as  generally  practised  has  been 
unsatisfactory,  but  chiefly  so  for  the  reason  that  the  proper  measures 
for  continuous  jaw  movement  have  not  usually  been  instituted. 
When  this  has  been  done  there  has  been  failure  to  continue  for  a 
sufficiently  long  period.  Nevertheless  in  spite  of  every  care  in  the 
effort  to  continue  the  free  movement  of  the  jaws,  it  may  be  impossible 
to  overcome  the  tendency  to  restricted  motion.  This  is  indicated  by 
the  complete  history  of  the  child  shown  in  Fig.  200  and  again  in  Fig. 
202.  The  development  of  the  molar  teeth  in  this  case  led  to  conditions 
which  caused  recurrence  of  the  jaw  fixation,  long  after  complete  success 
seemed  to  have  been  assured. 


Fig.  197. — Child,  aged  two  and  one- 
half  years,  with  ankylosis  of  the  lower 
jaw  from  the  day  of  birth.  The  reced- 
ing chin  shows  the  typical  arrested  devel- 
opment of  the  mandible. 


Fig.  198. — Same  child  as  shown  in 
Fig.  197.  The  chin  is  drawn  to  the  left, 
the  side  that  was  found  to  be  affected  by 
fibrous  ankylosis. 


Figs.  197  and  198  illustrates  a  little  girl,  aged  two  and  one-half 
years,  with  ankylosis  from  birth.  No  instruments  were  used  in  delivery, 
but  the  mother  was  a  number  of  hours  in  labor  and  there  was  without 
doubt  some  injury  to  the  jaw  by  reason  of  this  fact.  From  this  case 
and  other  similar  ones  that  the  author  has  seen  it  seems  to  him  fairly 
certain  that  ankylosis  of  this  character  is  brought  about  by  backward 
dislocation  of  the  jaw  through  some  traumatic  injury  during  labor. 
It  is  interesting  to  note  by  way  of  emphasizing  the  value  of  the  simple 
diagnostic  signs,  that  eighteen  difi'erent  medical  and  surgical  practi- 
tioners had  examined  this  child  without  being  able  to  determine  whether 
the  affection  was  unilateral,  bilateral,  fibrous,  or  bony.  Diagnosis 
was  made  of  fibrous  ankylosis  because  there  was  slight  but  distinct 
movement  of  the  jaw  upon  manipulation.    The  chin,  as  will  be  noted, 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION     371 

is  ii})on  one  side  of  the  central  facial  line.  Therefore  it  was  believed  to 
be  unilateral.  At  the  time  of  operation  this  proved  to  be  correct. 
The  child  was  given  a  general  anesthetic,  and  with  complete  relaxation 
a  thin,  flat  instrument  was  passed  between  the  teeth.  By  continued 
a])plication  of  steady  force  it  was  then  possible  to  slip  an  ordinary 
mouth  gag,  with  the  flanges  filed  down  so  as  to  leave  two  flat  surfaces 
to  slide  between  the  teeth,  in  through  the  space  caused  by  the  overbite 
of  the  upper  jaw  projecting  beyond  the  undeveloped  lower  jaw.  This 
permitted  the  passage  of  the  blade  of  a  knife  and  a  blunt  instrument 
to  be  used  as  a  director  through  ^^■hich  the  most  prominent  fibrous 
bands  were  located  and  then  severed.  With  each  incision  there  was 
a  noticeable  improvement  in  opening  the  jaw,  and  with  continued 
pressure  it  was  finally  possible  to  pass  a  finger  into  the  mouth  between 
the  teeth.  With  this  as  a  guide  the  knife  could  follow  until  all  of  the 
restricting  bands  of  tissue  were  cut  and  the  jaw  opened  to  its  full 
extent.  Every  movement  indicated  without  question  that  there  was 
no  serious  obstruction  upon  the  opposite  side.  The  teeth  should  first 
be  protected  by  a  metal  or  other  plate,  to  prevent  injury  from  the  gag. 

Postoperative  Treatment. — It  must  be  recognized:  (1)  That  the 
jaw  must  be  kept  continuously  open  or  in  free  movement  for  a  long 
period  of  time;  otherwise  there  will  be  recurrence  and  a  condition 
probably  worse  than  before  the  operation.  (2)  Unless  the  jaws  are 
kept  widely  open  both  day  and  night,  the  healing  proces^.  during  the 
sleeping  hours  will  more  than  overcome  what  might  be  accomplished 
during  the  daytime.  (3)  That  any  kind  of  an  appliance  which  a  young 
child  would  be  likely  to  fear  would  cause  so  much  disturbance  and 
difficulty,  perhaps  fighting  and  struggling  in  efforts  to  keep  it  between 
the  jaws,  that  it  would  be  unreasonable  to  expect  parents  to  carry  on 
such  methods  regularly  and  continuously  for  a  sufficiently  long  period 
of  time. 

To  meet  these  requirements  the  author  employs  a  very  simple 
expedient  which  has  been  useful  in  many  similar  and  large  numbers 
of  other  kinds  of  cases  in  which  it  was  necessary  to  keep  the  jaws  open. 
The  device  consists  of  a  series  of  rubber  corks,  to  which  for  safety 
several  inches  of  string,  ligature,  or  cord  have  been  firmly  attached  to 
prevent  accident  in  case  one  might  slip  into  the  throat  and  be  swallowed. 
The  smallest  size  of  these  can  be  readily  slipped  between  the  teeth  and 
graduall}'  forced  backward  without  frightening,  giving  pain  or  other 
serious  inconvenience  to  the  child.  A  larger  size  can  then  be  inserted 
on  the  opposite  side  of  the  mouth  and  gradually  forced  back  in  the  same 
way.  Continuing  from  one  side  to  the  other  the  fourth  or  fifth  larger 
cork  can  finally  be  placed  between  the  teeth.  Any  reasonably  disci- 
plined child  can  be  induced  to  keep  a  cork  of  that  kind  constantly  in 
the  mouth,  for  it  gives  practically  no  inconvenience.  The  little  girl 
whose  case  is  described  used  to  amuse  herself  and  play  with  her  dolls 
with  the  cork  between  the  teeth  without  any  trouble  whatever,  and 
slept  with  the  jaws  in  the  same  situation.    Thus  they  were  kept  con- 


372 


DISEASES  OF  BONE 


tiniioiisly  apart  for  many  months,  and  even  now,  after  a  lapse  of  several 
years,  the  mother  continues  to  stretch  the  parts  occasionally  in  this 
way.    Impro^•ement  in  the  shape  of  the  face  and  the  lower  jaw  with 


Fig.   199.— Child  shown  in  Fitrs.   197  Fig.  200.— Result    of    operation    for 

and  198,  -with  cork  between  the  jaws  as         fibrous    ankylosis.     Same    child    as   in 
described.  Figs.  197  and  198. 


Fig.  201. — Shows  the  scar  of  the  external 
operation  for  ankylosis  about  three  weeks 
after  operation.  The  hair  that  was  shaved 
above  the  flap  w-ill  almost  entirely  cover  the 
defect  when  grown  again,  and  the  scar  will  be 
much  less  noticeable  in  all  respects. 


Fig.  202. — Same  girl  shown  in 
Fig.  201  after  operation.  Previ- 
ously there  was  almost  complete 
fixation  of  the  jaws. 


almost  complete  free  movement. has  been  the  result.  Figs.  199  and 
200  are  pictures  of  the  same  child,  shown  in  Figs.  197  and  198,  with 
the  cork  in  place  as  described,  and  after  operation. 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    373 

The  eruption  of  the  molar  teeth  backward,  toward  the  angle  of  this 
typically  short  mandible,  created  conditions  which  brought  about  a 
more  or  less  gradual  limitation  of  movement  until  finally,  about  the 


Fig.  203. — Unilateral    fibrous    ankylosis; 
chin  drawn  toward  the  affected  side. 


Fig.  204. — Same  girl  shown  in  Fig.    2U3, 
attempting  to  open  her  mouth. 


Fig. 


205. — Picture  of  the  same  girl  as  in  Figs.  203  and  204,  opening  her  mouth   after 

operation. 


age  of  thirteen  years,  the  ankylosis  was  again  complete.  An  attempt 
was  again  made  to  force  the  jaws  apart  under  anesthesia,  but  it  was 
found  impossible  to  do  this  without  serious  injury  to  the  teeth.     It 


374 


DISEASES  OF  BONE 


therefore  became  necessary  to  do  the  external  operation  according  to 
Murphy's  method,  the  result  of  which  is  shown  in  Figs.  201  and  202. 
Figs.  203,  204  and  205  show  a  little  girl  for  whom  the  intra-oral 
operation  was  performed  for  unilateral  fibrous  ankylosis,  resulting 
from  aural  disease.  It  Avill  be  noticed  that  beginning  at  a  later  period 
there  is  not  the  same  amount  of  recession  of  the  chin,  because  the  lower 
jaw  has  developed  normally  until  the  beginning  of  the  trouble.  The 
diagnosis  of  unilateral  afl'ection  was  made  from  the  fact  that  the  chin 
was  upon  one  side  of  the  central  line,  and  it  was  found  to  be  correct, 
for  free  movement  was  secured  immediately  upon  separation  of  the 
restrictions  upon  the  affected  side.  Fig.  20G  is  a  skiagraph  of  the  case 
illustrated  in  Figs.  203,  204  and  205. 


Fig. 


206. — Skiagraph  of  a  case  of  fibrous  ankylosis.     The  same  one  illustrated  in 
Figs.  203,  204  and  205. 


Bony  Ankylosis. — Etiology. — Bony  ankylosis  results  from  a  distinc- 
tive t}T)e  of  arthritis,  which  may  be  due  to  any  one  of  the  diseases 
that  may  cause  the  latter  affection,  particularly  such  as  are  accom- 
panied by  suppurative  processes.  It  may  also  be  brought  about  by 
calcific  changes  such  as  occur  in  osteo-arthritis  or  result  from  traumatic 
injuries  which  may  destroy  the  integrity  of  the  parts  and  lead  to  infec- 
tion. Roe  believes  that  bony  ankylosis  resulting  from  such  injuries  is 
always  accompanied  by  fracture.  In  the  author's  experience  a  quite 
common  cause  of  both  true  and  false  ankylosis  is  the  extension  of  sup- 
purative aural  diseases.    The  case  illustrated  in  Fig.  207  with  bilateral 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    375 

ankylosis  began  after  extensive  suppuration,  which  affected  the  ear 
upon  one  side  and  later  upon  the  other.  Others  of  the  author's  cases 
have  given  a  similar  history. 

Symptoms. — Absolute  immobility  of  the  lower  jaw  is  the  dominant 
symptom.  In  cases  where  the  affection  has  begun  at  birth,  infancy, 
or  early  childhood  there  is  arrested  development  of  the  lower  jaw, 
which  remains  approximately  the  size  that  it  was  at  the  period  of  onset 
of  the  affection.  There  is  corresponding  recession  of  the  chin  and  lack 
of  development  of  the  lower  part  of  the  face,  with  marked  projection 
of  the  upper  jaw.  This  is  fortunate  for  the  patients,  as  it  enables  them 
to  pass  food  through  the  mouth  and  to  secure  sufficient  nourishment 
without  movement  of  the  mandible.  Contrary  to  expectation,  the 
general  health  and  appearance  of  these  individuals  is  usually  fairly 
good.    Figs.  208  and  209  are  radiographs  of  adults  with  bony  ankylosis. 


Jig.  207. — Bilateral  bony  ankylosis. 

Prognosis. — In  operations  for  the  relief  of  bony  ankylosis  the  chief 
danger  lies  in  asphyxia.  Usually  the  cases  that  prove  troublesome 
in  this  respect  are  also  those  in  which  there  has  been  difficult  breathing 
before  operation  was  performed,  and  from  this  history  the  operator 
may  be  on  guard.  Safety  depends  upon  readiness  to  meet  the  situation 
both  during  and  after  the  operation.  The  result  necessarily  depends 
very  largely  upon  the  character  of  the  cause  and  the  actual  condition 
of  the  ankylosis.  If  operation  upon  the  condyles  can  give  sufficient 
movement  without  restriction  from  anterior  attachments,  then  a 
good  permanent  result  may  be  expected.  If  such  bands  exist  and  the 
condition  is  unilateral,  there  will  be  sufficient  force  in  mastication  from 
the  muscles  of  the  unaffected  side  to  overcome  disadvantage  of  the 


376 


DISEASES  OF  BONE 


loss  of  functionating  power  upon  the  side  from  which  a  section  of  the 
jaw  has  been  resected.    When,  however,  the  ankylosis  is  bilateral  and 


Fig.  208. — -Radiograph  of  an  adult  with  bony  ankylosis. 


Fig.  209. — -Radiograph  of  an  adult  with  bony  ankylosis. 


of  such  character  as  to  make  it  impossible  to  give  relief  by  operating 
upon  the  cond^^les,  resection  according  to  the  Esmarch  operation  upon 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    377 

both  sides  leaves  little  or  no  muscular  strength  for  use  of  the  jaw  in 
mastication.  If  such  ])atients  are  A\'ell  nourished  and  getting  on  com- 
fortably without  operation,  it  is  the  author's  belief  that  they  should 
be  left  undisturbed,  for  bilateral  Esmarch  operation  ought  not  to  be 
performed  except  in  rare  cases  of  urgent  necessity. 

Treatment. — The  purpose  of  all  methods  of  treatment  of  bony  anky- 
losis is  to  establish  a  pseudarthrosis.  Among  the  various  operations 
devised  for  this  purpose  are  the  following:  Removal  of  a  segment  from 
the  body  of  the  jaiv  near  the  angle,  already  referred  to  as  Esmarch's 
operation;  division  of  the  ascending  ramus,  as  recommended  by  Dieff en- 
bach;  separation  of  the  jaw  hy  cutting  with  forceps  used  from  within  the 
month  anterior  to  the  cicatricial  band  causing  fixation  as  recommended 
by  Rizzoli;  many  variations  of  the  three  preceding  operations,  as 
suggested  by  Elliot  and  Cabot,  of  Boston,  Whitehead,  of  Manchester, 
and  others;  remjoval  of  wedge-shaped  sections  from  the  ramns  and  the 
insertion  of  gauze  or  gutta-yercha  tissue,  muscle,  or  other  tissue  or  skin 
to  prevent  reuniting  of  the  parts,  as  recommended  by  jNIcIllhenny  and 
Gluck,  of  Berlin,  who  implanted  a  cutaneous  u'edge  with  attachment 
to  the  bony  surfaces  to  prevent  union;  excision  of  the  head  and  neck  of 
the  condyle,  first  performed  by  Humphrey  in  1856;  and  removal  of  a 
section  of  the  jaiv  in  front  of  the  fibrous  bands. 

Excision  of  a  section  from  the  neck  of  the  condyle  without  removal  of 
the  head  and  then  insertion  of  a  flap  of  tissue.  This  operation  was 
perfected  by  the  late  Dr.  John  B.  Murphy.^  Modifications  of  his 
method  which  are  now  generally  followed  with  much  success  by  many 
operators  are  illustrated  in  Figs.  210-213.  The  incision  is  L-shaped,  the 
perpendicular  portion  comes  down  to  the  upper  border  of  the  zygoma 
and  then  extends  for^^■ard  for  one-half  to  three-quarters  inch,  making 
the  longitudinal  portion.  This  incision  leaves  a  very  slight  scar,  and 
gives  better  access  than  does  the  perpendicular  incision,  because  in 
some  of  the  cases  the  ankylosis  extends  for^^'ard  on  the  zygoma  from 
the  glenoid  to  the  coronoid  process.  The  perpendicular  incision  is  for 
securing  the  fat  and  fascia  of  the  temporal  muscle. 

For  dividing  the  ankylosis  the  chisel  is  more  satisfactory  than  the 
bur.  The  greatest  caution  is  required  in  the  use  of  the  chisel  or  the 
bur,  because  the  brain  is  separated  by  a  very  thin  plate  of  bone  only. 

After  the  incision  the  edges  of  the  wound  are  retracted,  the  lower 
lip  being  displaced  do^^■n  over  the  lower  border  of  the  zygoma,  to  give 
a  good  exposure  of  the  joint.  Then  the  tissues  are  separated  with  a 
special  curved  periosteotome  all  around  the  anterior  surface  of  the 
line  of  union  and  further  separated  with  a  similar  instrument  around 
the  posterior  surface.  When  the  bone  is  laid  bare,  the  instruments 
are  passed  behind  the  neck  of  the  bone,  one  from  each  side;  when  they 
are  in  place  they  completely  encircle  the  neck,  holding  the  soft  parts 
retracted  so  the  articulation  is  fully  exposed.    The  insertion  of  these 

1  Practical  Medicine,  Series  11,  1915. 


378 


DISEASES  OF  BONE 


Fig.  210. — The  Gigli'saw  used  to  divide  the  mandible. 


Fig.  211. — The  gap  left  after  the  exsection,  with  the  curved  periosteotomes  still  in  situ. 
Figs.  210  and  211. — Arthroplasty  for  intra-articular  ankylosis  of  jaw.     (Miu-phy.) 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    379 


Fig.  212. — The  temporal  fascia  and  fat  flap  freed  and  prepared  for  insertion. 


Fig.   213.— The  temporal  fascia  and  fat  flap  secured  in  its  interposing  position  by  sutures. 
Figs.  212  and  213. — Arthroplasty  for  intra-articular  ankylosis  of  jaw.     (Murphy.) 


380 


DISEASES  OF  BONE 


instruments  and  their  retention  during  excision  form  the  key  to  the 
success  and  safety  of  the  operation.  Injury  to  the  internal  maxillary 
artery,  which  closely  hugs  the  neck,  is  thus  avoided.  The  chisel  or 
bur  then  divides  the  bone  on  the  level  of  the  tubercle,  without  endeavor- 
ing to  remove  the  articular  surface  of  the  head  of  the  bone,  as  there  is 


Fig.  214. — Arthroplasty  for  intra-articular  ankylosis  of  jaw.  (Murphy.)  A,  B, 
Dr.  Murphy's  periosteotome,  side  and  back  view  (somewhat  reduced);  C,  D,  bone- 
cutting  forceps  or  nippers,  side  and  front  view  (somewhat  reduced) ;  E,  the  interdental 
block  designed  by  Dr.  Murphy  to  maintain  the  desired  spread  of  the  jaws.  It  is  made 
of  wood,  and  since  it  is  wedge-shaped  the  degree  of  opening  can  easily  be  regulated  by 
withdrawing  or  pushing  in  the  block. 

danger  of  penetrating  the  base  of  the  skull  when  an  effort  is  made  to 
excavate  all  of  the  head.  If  bony  ankylosis  is  present,  one-third  inch 
of  the  neck  is  excised,  so  one  can  put  the  tip  of  the  finger  between  the 
divided  fragments  across  the  space  over  the  inner  margin  of  the  neck 
at  the  base  of  the  zygoma.  This  must  be  done  carefully,  and  ample 
bone  removed,  so  as  to  admit  the  interposing  flap.    The  periosteum 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION     381 

should  be  left  attached  to  the  bone  that  is  removed.  The  deeper 
fragments  of  bone  can  be  taken  out  with  a  small  ronguer.  If  one 
desires,  as  soon  as  the  periosteotomes  have  been  passed  behind  the  neck 
of  the  bone,  a  small  and  full-curved  aneurysm  needle  may  be  used  to 
carry  a  silk  thread  around  the  neck  to  act  as  the  carrier  for  the  Gigli 
saw;  this  method  is  rapid  and  effective.  The  difficulty  of  inserting 
the  saw  is  slight,  but  the  acute  angulation  which  necessarily  occurs, 
occasionally  causes  it  to  break,  giving  some  inconvenience.  On  the 
whole,  it  is  not  handled  as  easily  as  the  chisel.  As  soon  as  the  bone  is 
completely  di\'ided,  the  mouth  can  be  opened  readily  by  the  anesthetist. 

The  interposing  flap  should  now  be  prepared.  The  perpendicular 
incision  is  elongated  up,  say  for  one  and  one-half  inches  over  the  tem- 
poral muscle,  about  three-quarters  inch  wide  and  one  and  one-half 
inches  long,  leaving  the  base  attached  to  upper  margin  of  the  zygoma. 
This  is  freed  from  above  down,  folded  down  over  zygoma  and  packed 
into  the  bony  gap,  from  which  a  portion  of  the  neck  has  been  removed. 
At  its  anterior  and  posterior  basal  angles  it  is  securely  tacked,  with  a 
few  catgut  sutures,  to  the  fascia  and  periosteum,  so  as  to  retain  it  in 
position.  Then  the  skin  is  accurately  closed  with  horsehair,  dusted 
with  bismuth  subiodide  and  sealed  with  collodion  gauze.  No  other 
dressing  needs  to  be  applied. 

No  special  effort  should  be  made  at  this  time  to  spread  the  jaws, 
as  it  is  important  the  lower  jaw  should  remain  steadied  on  the  well 
side  in  order  that  the  wooden  block  inserted  on  the  diseased  side  may 
maintain  the  wide  separation  of  the  molar  teeth,  until  the  inter- 
posing flap  has  healed  in.  This  block  also  prevents  compression  and 
necrosis  of  the  flap. 

Babcock  transplants  fat  from  some  other  portion  of  the  body  into 
the  space  between  the  ends  of  the  bone.  This  saves  the  necessity  for 
the  perpendicular  incision.  Dr.  Morris  I.  Schamberg,  of  New  York, 
recently  exhibited  a  very  successful  result,  although  he  placed  no 
tissue  between  the  bone  ends  in  that  case.  The  author  has  found 
it  easier  to  insert  the  flap  of  fascia  as  described  by  Murphy,  and 
although  Murphy's  instruments,  as  shown  in  Fig.  214,  would  undoubt- 
edly facilitate  the  accomplishment  of  the  operation,  he  has  found 
little  difficulty  in  securing  the  desired  results  with  quite  simple  instru- 
ments, devised  to  meet  the  operative  requirements. 

Roe's  description  of  the  operation  for  excision  of  the  head  and  neck 
of  the  condyle  in  the  report  of  one  of  his  cases  is  valuable.    He  says:^ 

"I  made  an  incision  opposite  the  neck  of  the  condyle,  beginning 
just  below  the  zygoma  and  extending  downward  one  and  one-half 
inches.  The  anterior  border  of  the  parotid  gland  was  next  retracted 
backward,  exposing  the  masseter  muscle.  With  the  blunt-pointed 
dissector  I  separated  the  fascia  and  fibers  of  the  masseter  muscle  and 
periosteum  about  opposite  the  middle  of  the  skin  incision  forward, 

1  National  Dental  Association,  1902.  pp.  92  to  94. 


382  DISEASES  OF  BONE 

dilating  this  opening  with  forceps  until  I  could  introduce  my  two 
index  fingers.  Through  this  opening  I  made  a  subperiosteal  excision 
with  a  chisel  of  the  mass  of  callus,  including  the  condyle  and  neck,  and 
found  that  the  bridge  of  bone  connected  the  outer  surface  of  the  head 
and  neck  of  the  condyloid  process  with  the  outer  surfaces  and  lower 
border  of  the  posterior  portion  of  zygoma,  and  was  about  one-third 
of  an  inch  in  thickness  and  three-quarters  in  width.  There  was  no 
union  between  the  articular  surfaces,  and  an  apparent  absence  of  the 
interarticular  fibrocartilage.  After  clearing  the  lower  border  of  the 
zygoma  and  making  smooth  the  excised  border  of  the  ramus,  I  was 
able  to  pass  my  index  finger  freely  between  the  ramus  and  glenoid 
fossa,  and  could  spread  the  mandible  sufficiently  to  demonstrate  that 
it  was  free  upon  that  side,  except  for  its  muscular  attachments.  After 
carefully  flushing  with  water  to  remove  any  chips  of  bone,  I  brought 
together  the  separated  fibers  of  the  masseter  muscle  and  fascia  with 
catgut  sutures,  afterward  closing  the  skin  wound  A\ith  Halstead's 
subcuticular  suture,  using  silkworm  gut.  (Gregg  has  recommended 
closing  the  wound  without  drainage.)  The  same  procedure  was 
repeated  upon  the  left  side,  and  almost  precisely  the  same  condition 
of  the  articulation  was  found.  As  soon  as  the  section  through  the  neck 
of  the  condyle  was  complete,  the  mandible  dropped  a  little  distance. 
When  I  had  completed  the  excision,  and  before  closing  the  wound,  I 
placed  an  ordinary  mouth  gag  between  the  teeth  and  opened  the 
mouth  to  about  the  normal  extent,  and  then  by  grasping  the  mandible 
I  made  some  lateral  manipulations,  after  which  the  Mound  M'as 
closed. 

"There  was  no  special  interference  with  respiration  during  either 
operation,  and  the  patient  made  a  rapid  and  uninterrupted  recovery 
from  each.  The  wound  healed  by  primary  union,  and  in  each  case  the 
sutures  were  removed  on  the  eighth  day.  He  was  allowed  to  open  his 
mouth  as  freely  as  the  bandages  would  permit,  and  ten  days  after  the 
second  operation,  when  he  left  for  his  home,  he  could  voluntarily 
separate  the  anterior  teeth  to  the  extent  of  one  inch,  and  was  learning 
to  masticate  solid  food.  Three  weeks  later  he  could  open  his  mouth 
one  and  one-fourth  inches.  There  was  paralysis  of  the  muscles  supplied 
by  the  malar  and  infra-orbital  branches  of  the  temporofacial  division 
of  the  seventh  nerve,  from  which  he  gradually  and  almost  completely 
recovered  in  two  months.  He  has  actively  exercised  the  muscles 
connected  with  the  mandible,  and  at  the  present  time  can  open  his 
mouth  one  and  one-quarter  inches,  can  close  it  with  about  as  much 
force  as  the  ordinary  person,  and  has  good  lateral  motion." 

In  describing  other  -cases.  Roe  calls  attention  to  one  in  which  a 
tracheotomy  was  necessary  to  overcome  arrested  respiration  when  the 
mouth  was  opened  after  the  jaw  had  been  freed  from  its  attachments. 
He  reports  the  case  of  another  patient  who  died  from  arrested  respira- 
tion almost  without  warning  after  he  had  been  returned  to  his  room 
in  the  hospital  apparently  in  good  condition.    In  this  case  local  anes- 


AFFECTIONS  OF  TEMPOROMANDIBULAR  ARTICULATION    383 

thesia  was  used  because  of  the  danger  apprehended  from  a  general 
anesthetic.  Dr.  Wayne  Babcock,  of  Philadelphia,  also  reports  one  case 
in  which  death  occurred  quite  unexpectedly  after  the  patient  had  been 
returned  from  the  operating  room. 

Roe  believed  that  through  absence  of  development  of  the  mandible 
in  these  individuals  the  hyoid  bone  is  not  raised  to  its  proper  position, 
and  that  it  is  displaced  back^^■ard  and  downward,  causing  displace- 
ment of  the  organs  dependent  upon  it.  Thus  it  leaves  very  little 
phar^Tigeal  space,  and  when  the  mandible  is  freed  from  its  attachment 
and  drops  to  some  extent,  the  base  of  the  tongue  and  the  posterior 
surface  of  the  lar\Tix  lie  in  apposition  to  the  posterior  pharyngeal  wall. 
Thus  respiration  is  difficult  or  impossible. 

Esmarch's  Operation. — ^An  incision  about  two  inches  in  length  is 
made  along  the  lower  border  of  the  jaw.  The  bone  is  exposed,  the 
periosteum  di\'ided,  and  a  wedge  of  bone  with  its  base  below  removed 
from  the  body  of  the  jaw  anterior  to  the  masseter  muscle  and  in  front 
of  the  contracted  tissue,  bleeding  checked,  and  the  wound  closed. 
Passive  movements  must  be  begun  as  soon  after  the  operation  as  prac- 
ticable and  continued  regularly.  Corks  between  the  teeth  to  keep  the 
mouth  open  as  \\  idely  as  possible  should  be  employed  as  already  out- 
lined for  fibrous  ankylosis.  It  is  only  under  very  rare  conditions  that 
this  operation  might  be  required. 

Postoperative  Treatment. — The  jaw  must  be  firmly  secured  to  pre- 
vent its  dropping  and  causing  suffocation  until  such  time  as  the  patient 
may  have  quite  recovered  from  the  anesthetic  and  has  had  some 
opportunity  to  become  accustomed  to  new  conditions  in  respiration. 
At  a  later  period  and  before  adhesions  have  had  opportunity  to  become 
sufficiently  resistant,  motion  of  the  jaw  should  be  instituted  and 
continued  until  a  permanent  result  is  secured.  In  other  respects  the 
treatment  of  these  patients  is  the  same  as  for  other  operations  subject 
to  more  than  ordinary  care  in  administering  nourishment  under  the 
difficult  conditions  that  are  imposed. 

Arthrodesis. — This  term  is  applied  to  the  intentional  production  of 
ankylosis  in  a  joint  previously  healthy  or  nearly  so  with  the  intention 
to  stiffen  and  enhance  its  usefulness.  This  is  usually  required  in  cases 
of  infantile  paralysis  with  loss  of  control  of  the  extremities.  It  is  also 
in  a  measure  applicable  to  cases  of  too  free  movement  of  the  condyle 
in  the  temporomandibular  fossa  from  habit,  relaxed  conditions  of  the 
ligaments  and  muscles,  when  temporary  immobility  of  the  jaws  is 
secured  or  other  methods  of  fixation  for  the  purpose  of  gaining  a 
measure  of  stiffness  in  motion,  and  it  is  undoubtedly  upon  this  prin- 
ciple that  the  various  expedients  for  jumping  the  bite  are  enabled 
to  operate  successfully. 

In  other  parts  arthrodesis  is  sometimes  brought  about  by  opening 
into  the  joint  itself  to  stiffen  more  firmly  than  might  be  expected  from 
less  heroic  methods. 


384 


DISEASES  OF  BONE 


RESECTIONS    OF   THE   JAWS. 

The  purposes  of  resection  of  the  maxilhTe  are  for  removal  of  the 
maHgnant  growths,  correction  of  deformities,  and,  as  ah*eady  de- 
scribed, the  formation  of  a  false  joint  in  treatment  of  ankylosis.  In 
addition  to  this,  large  sections  of  bone  involving  the  entire  thickness 
of  the  body  of  the  jaw  are  sometimes  removed  as  sequestra  in  the 
treatment  of  necrosis. 

Resections  of  the  Lower  Jaw. — The  several  forms  of  resection  of  the 
lower  jaw  are  as  follows: 

Temporary,  when  the  jaw  is  resected  to  facilitate  the  performance 
of  some  operation  in  the  mouth  or  pharynx  and  immediately  closed 
as  illustrated  in  Fig.  215. 


Fig.  215. — Temporary  resection  of  the  inferior  maxilla.     (After  Sedillot.) 

Partial,  without  complete  division  of  the  jaw. 

Complete,  ^hen  the  jaw  is  completely  divided. 

Disarticulation,  when  the  articular  portion  is  removed. 

Partial  Resection. — Resections  involving  the  alveolar  process  or  part 
of  the  body  of  the  jaw  can  under  normal  conditions  be  performed 
svithout  an  external  incision.  Provision  must  be  made  against  the 
inspiration  of  blood,  as  with  other  mouth  operations.  The  patient 
is  placed  in  a  recumbent  position  with  the  shoulders  raised  by  a  pad 
or  sand-bag  sufficiently  to  tip  the  head  as  far  back  as  possible  when 
turned  as  it  should  be  toward  the  side  away  from  that  which  is  to  be 
operated  upon.  The  lips  and  angle  of  the  mouth  are  held  out  of  the 
way  with  a  retractor,  a  gauze  sponge  made  into  a  roll  and  clasped 
with  a  forceps  placed  along  the  inside  of  the  jaw  under  the  tongue. 
In  this  way  the  field  of  operation  may  be  satisfactorily  exposed  and 
the  flow  of  blood  kept  within  bounds.  Bone  shears  or  bone-cutting 
forceps  sometimes  facilitate  removal  of  the  bone,  or  a  chisel  may  be 
used.     But  there  seems  to  be  no  reasonable  doubt  of  the  fact  that 


RESECTIONS  OF  THE  JAWS  385 

in  these  cases  a  surgical  engine  bur,  or  bone-cutting  burs  for  the 
dental  engine,  as  described  (p.  76),  ^^■ill  efl'ect  the  necessary  removal 
more  rapidly  with  less  hemorrhage,  because  the  torsion  of  the  vessels 
by  the  rotary  motion  of  the  bur  favors  their  contraction  and  lessens 
the  flow  of  blood.  A  properly  manipulated  bur  leaves  a  smooth  bone 
surface,  which  favors  healing  processes.  If  resection  be  made  for  any 
purpose  other  than  malignant  growths,  and  when  the  periosteum  is 
not  actually  involved  in  disease  which  necessitates  its  removal,  or  in 
cases  where  it  is  not  desirable  to  ha\'e  pseudo-arthrosis,  this  mem- 
brane should  be  carefully  preserved  to  as  great  an  extent  as  possible, 
in  order  that  bone  may  again  be  restored  with  a  maximum  of  functional 
usefulness  and  minimum  of  deformity. 

In  the  performance  of  all  such  operations  within  the  mouth  it  should 
be  remembered  that  both  control  of  hemorrhage  and  proper  care  of 
the  wound  surface  to  promote  healing  processes  may  depend  upon  the 
satisfactory  retention  of  a  packing.  The  outline  of  the  wound  cavity 
should  therefore  be  clearly  defined  and  so  formed  as  to  facilitate  both 
the  insertion  and  the  retention  of  such  a  packing.  It  is  the  author's 
practice  to  use  plain  sterile  gauze  in  the  form  of  a  long,  na^ro^^"  packing 
strip,  with  all  the  frayed  edges  of  the  gauze  so  folded  that  there  will 
be  no  likelihood  of  shreds  becoming  detached  and  clinging  to  the 
wound  siu-face  to  give  trouble  after  its  removal.  This  is  wrung  out 
in  2.5  per  cent,  carbolic  or  1  to  10,000  bichloride  of  mercury.  Any 
other  suitable  antiseptic  will  do  as  well.  ^Mien  the  wound  cavity  is 
almost  filled  a  small  portion  of  the  end  of  the  packing  is  saturated  with 
collodion,  packed  into  position,  and  the  surface  again  sealed  with 
collodion.  All  such  packings,  especially  when  inserted  during  anes- 
thesia, should  have  a  piece  of  ligature  attached  which  can  be  carried 
out  around  the  corner  of  the  mouth  and  fixed  upon  the  surface  of  the 
cheek  with  a  small  piece  of  adhesive  plaster.  In  this  way  the  danger 
that  the  packing  may  become  dislodged  and  be  swallowed  during 
sleep  is  avoided,  and  removal  is  easily  accomplished  by  drawing  it 
out  with  the  ligature.  It  is  sometimes  advisable  to  leave  such  a 
packing  in  the  mouth  forty-eight  hours  after  the  operation,  but  later 
packings  should  be  changed  daily.  Once  or  twice  a  day  the  buccal 
mucous  membrane  surfaces  of  lips,  cheeks,  tongue  and  palate  as 
well  as  the  tooth  surfaces,  should  be  cleansed  with  applicators  dipped 
in  dioxogen,  and  instructions  given  to  have  such  patients  hold  in 
their  mouths  2.5  per  cent,  carbolic  acid  or  other  mouth  wash  used 
alternately  with  the  dioxogen  once  each  hour  during  the  day. 

Complete  Resection. — Complete  resection  of  the  lower  jaw  may  be 
performed  from  within  the  mouth,  as  described  for  partial  resections, 
or  by  skin  incisions  along  the  lower  border  of  the  jaw  or  through  the 
central  portion  of  the  chin  and  lower  lip  or  both,  or  the  vertical  inci- 
sion may  extend  up  to  but  not  include  the  lip  border,  according  to  the 
situation  and  character  of  the  affection  of  jaw  that  is  to  be  resected. 
\Yhen  large  segments  have  to  be  removed  the  external  incision  is  by 
25 


386  DISEASES  OF  BONE 

all  means  more  satisfactory.  Not  only  can  the  operation  be  per- 
formed with  less  fear  of  hemorrhage,  but  there  is  a  tendency  in  any 
event,  when  intrabuccal  resection  is  performed,  for  secretions  of  the 
mouth  to  lodge  and  form  a  pouch  in  the  situation  of  the  wound. 
The  almost  invariable  result  of  this  is  an  opening  through  the  external 
surface,  which  is  quite  likely  to  cause  as  much  or  more  scar  and  deform- 
ity as  a  properly  made  skin  incision.  Treves^  emphasizes  Heath's 
suggestion  that  it  is  not  wise  to  cut  completely  through  one  section 
before  the  other  is  begun;  that  by  cutting  almost  through  the  jaw 
at  one  point,  and  again  nearly  through  the  other,  the  steadiness  thus 
retained  facilitates  rapid  work  and  prevents  the  irritation  of  the 
rubbing  of  the  ends  of  the  bone,  which  all  who  have  performed  this 
operation  know  to  be  exceedingly  annoying.  The  excision  can  be 
completed  by  rapidly  completing' each  cut  (Figs.  216  and  217). 


Fig.  216. — Outline  of  the  incision  for  resection  of  the  lower  jaw. 

When  a  neoplasm  is  the  cause  of  the  resection  the  structures  con- 
nected with  the  bone  must  be  removed,  including  the  periosteum, 
but  under  other  conditions  the  periosteum  should  be  preserved  with 
the  greatest  possible  care.  When  the  lower  lip  and  bone  are  divided 
in  the  medial  line  for  the  removal  of  a  section  of  the  jaw  in  that  region, 
there  is  danger  of  suffocation  if  the  tongue  is  allowed  to  fall  back  and 
close  the  entrance  to  the  larynx  when  the  genioglossal  and  geniohyoid 
muscles  are  divided.  In  anticipation  of  this  a  ligature  should  be 
passed  through  the  fleshy  portion  of  the  tongue  so  that  it  may  be 
drawn  upward  and  forward  and  held  in  that  position.  Most  surgeons 
prefer  the  Gigli  wire  saw  for  performing  the  resection.  The  author 
prefers  engine  burs,  as  already  stated.  Whatever  the  instrument 
may  be,  however,  it  is  desirable  to  avoid  splitting  or  chipping  the 
bone  and  to  have  smooth,  clean-cut  surfaces.  Hemorrhage  may  be 
controlled  by  packing  or  ligating  vessels  that  may  be  persistent. 

'  Treves:  Operative  Surgery,  ii,  291. 


RESECTIONS  OF  THE  JAWS  387 

Retention  of  the  Divided  Fragments. — It  is  important  to  prepare  the 
retention  appliance  in  advance  of  the  operation  when  this  can  be 
done  and  its  need  foreseen.  If  there  are  sonnd  teeth  in  the  jaw  at 
each  side  of  the  resected  portion,  crowns  may  be  fitted  in  advance  and 
a  piece  of  bridge-work  constructed  which  can  be  permanently  cemented 
into  place  as  soon  as  recovery  has  progressed  sufficiently  to  allow  its 
insertion.  This  will  serve  to  fixate  the  parts  with  the  additional  sup- 
port of  bandages  until  the  jaw  may  become  secure.  The  author  has 
usually  found  it  advisable  to  have  bridge-work  for  this  purpose  made 
removable.  Crowns  are  first  attached  to  teeth  beyond  the  line  of 
the  proposed  resection,  other  crowns  are  made  to  telescope  o^'er  these, 
and  the  bodv  of  the  bridge  is  made  of  vulcanite.     The  advantage  of 


Fig.  217. — Resection  of  the  lower  jaw. 

this  form  of  bridge  splint  is  that  it  gives  greater  cleanliness  over  a 
necessarily  uneven  and  changing  surface  than  fixed  bridge-work  as 
ordinarily  constructed,  and  that  it  can  be  altered  from  time  to  time 
as  the  jaw  fills  in.  A  modification  of  the  Angle  band  splints  may  be 
employed  with  additional  nuts  so  placed  that  by  turning  them 
force  may  be  applied  in  extension  to  prevent  drawing  together  of 
the  ends  of  the  bone  by  muscular  action  when  the  section  has  been 
removed,  as  well  as  to  retain  a  proper  alignment.  When  it  is  not 
practicable  to  hold  the  parts  by  either  of  the  foregoing  methods, 
crowns  upon  the  upper  and  lower  teeth  with  flanges  outside  the  line 
of  occlusion  of  the  upper  teeth  are  arranged  that  when  the  jaws  are 
closed  the  flange  will  pass  along  the  buccal  side  of  the  upper  teeth 


388 


DISEASES  OF  BONE 


and  force  the  lower  teeth  into  proper  alignment,  thus  securing  adjust- 
ment. This  is  a  modification  of  the  plan  first  adopted  by  the  Berlin 
dentists  Sauer  and  Siiersin.  The  purpose  of  this  is  to  overcome  the 
tendency  of  the  attached  section  of  the  lower  jaw  to  be  drawn  inward 
by   cicatricial  and  muscular  action.     Dr.   INIartin,   the   well-known 


Fjg.  218.- — Martin's  artificial  denture  for  the  support  of  a  resected  jaw. 

dentist  of  Lyon,  has  originated  many  ingenious  appliances  of  this 
character.  One  of  these,  shown  in  Fig.  218,  is  an  artificial  denture 
fitted  to  the  lower  jaw  and  behind  to  a  plate  which  rests  against  the 
palatine  surface  of  the  upper  jaw.  It  is  adjusted  so  as  to  allow  move- 
ment of  the  mandible,  and  flanges  are  attached  to  each  plate  in  such 


Fig.  219.  —  Martin's  plate  for 
a  resected  jaw. 


Fig.  220. — One  of  Martin's  appliances  for  a 
resected  lower  jaw,  with  tubes  for  irrigation 
purposes  attached. 


position  as  to  slide  past  each  other  and  to  permit  the  flange  from 
the  upper  plate  to  be  held  upon  the  inside  of  the  one  attached  to 
the  lower  when  the  mouth  is  closed,  and  thus  apply  the  necessary 
retention  of  correct  position.  Figs.  219  and  220  are  also  Martin's 
devices  for  resected  jaws. 


RESECTIONS  OE  THE  JAWS 


m 


Another  of  Martin's  valuable  suggestions,  termed  by  him  a  "pro- 
these  immediate,"  was  published  in  1889.  It  is  the  use  of  gutta- 
percha fashioned  to  occupy  the  resected  segment  of  the  jaw  and 
firmly  attached  to  the  remaining  portions.  This  material  is  easily 
molded  into  the  required  form  and  serves  to  hold  the  parts  during  the 
healing  processes.  Afterward  a  permanent  appliance  containing  teeth 
and  firmly  attached  to  the  bone  segments  by  screws  are  made  remov- 
able if  necessary.  It  is  used  to  supply  the  place  of  the  artificial 
fixture  (Fig.  221). 

Bull  reports  the  successful  use  of  Martin's  plan  in  the  case  of  a 
girl,  aged  eighteen  years,  in  whom  it  has  given  satisfactory  services 
for  eight  or  more  years.  A  temporary  splint  was  used  immediately 
after  the  operation,  and  a  permanent  splint  inserted  a  few  weeks 
later  which  the  girl  was  able  to  remove,  cleanse,  and  reinsert  without 
difficulty.     The  advantage  of  metal  splints  when  adaptable  is  obvious. 


Fig.  221. — -Martin's  artificial  jaw. 

Bonnecken,  Partsch,  and  Stoppany  have  undertaken  to  supply  this 
need,  as  is  shown  by  their  artificial  jaw  splints  illustrated  in  Figs. 
222,  223  and  224.  The  purposes  of  their  construction  are  sufficiently 
plain  without  detailed  explanation  except  that  Stoppany's  splint,  which 
is  made  of  ahmiinum,  is  designed  to  hold  the  soft  parts  of  the  chin 
in  position  and  to  prevent  the  deformity  which  is  likely  to  occur  with 
other  forms  of  support  which  do  not  have  this  feature. 

Disarticulation. — In  removal  of  one-half  of  the  lower  jaw  the  posi- 
tion of  the  patient  is  as  previously  described.  A  vertical  incision  is 
made  through  the  tissues  of  the  chin  in  middle  line  without  division 
of  the  lip,  and  incision  along  the  lower  border  of  the  jaw  to  the  angle 


390 


DISEASES  OF  BONE 


and  upward  behind  the  posterior  margin  of  the  ascending  ramus. 
Where  the  incision  crosses  the  facial  artery  only  the  skin  is  divided, 
the  artery  is  exposed  by  dissection  and  divided  between  two  liga- 


FiG.  222. — Bonnecken's  artificial  jaw. 


Fig.  223. — Partsch's  artificial  jaw. 


RESECTIONS  OF  THE  JAWS 


391 


tures.  The  skin  and  external  muscles  are  separated  together  in  the 
flap,  the  surface  of  the  bone  being  followed  closely.  The  mental 
and  masseteric  arteries  and  small  vessels  which  are  divided  can  be 
easily  controlled.  If  there  are  teeth  in  the  jaw  an  incisor  is  extracted 
and  the  jaw  divided  through  its  socket  at  or  near  the  median  line. 
The  muscles  are  stripped  from  the  inner  side  of  the  jaw  by  following 
the  bone  surface  closely  upon  the  external  surface.  The  geniohyoid, 
geniohyoglossus,  and  digastric  muscles  are  detached.  The  anterior 
portion  of  the  jaw  is  gradually  drawn  downward  and  outward,  the 
mylohyoid  and  ultimately  the  internal  pterygoid  muscles  are  dis- 


Fig.  224. — Stoppany's  artificial  jaw. 

seated  free.  The  inferior  dental  artery  and  nerve  are  exposed,  the 
artery  secured  and  divided.  By  drawing  the  bone  outward  and  keep- 
ing close  to  its  surface,  injury  and  sublingual  and  submaxillary  glands 
may  be  avoided.  By  depression  of  the  jaw  the  tendon  of  the  temporal 
muscle  may  be  detached  from  the  coronoid  processes  and  the  con- 
dyle exposed.  The  external  pterygoid  muscle  is  next  divided,  the 
capsule  of  the  joint  opened  and  the  bone  cut  free  from  the  internal 
lateral,  stylomaxillary,  and  pterygomaxillary  ligaments,  and  the  bone 
removed  (Fig.  225).  Treves  warns  against  laceration  of  the  internal 
maxillary  artery  by  contact  with  the  neck  of  the  bone  if  it  be  twisted 
or  rotated  in  removal.  Anyone  who  has  opened  the  internal  maxil- 
lary in  this  situation,  as  happened  in  one  of  the  author's  cases,  will 


392 


DISEASES  OF  BONE 


not  need  a  second  warning  to  be  careful  in  this  respect.  Tracheotomy 
is  seldom  necessary  in  these  cases  for  one  who  is  accustomed  to  operate 
in  this  field.  Removal  of  the  entire  lower  jaiv  is  credited  to  Blandin  in 
1848  as  the  first  surgeon  to  succeed  in  its  performance,  and  is  identical 
with  disarticulation  and  removal  of  one-half,  as  already  described, 
except  that  the  vertical  incision  through  the  chin  and  lower  lip  is 
unnecessary.  The  longer  time  required  for  the  operation  and  increased 
loss  of  blood  necessarily  involve  greater  shock  with  correspondingly 
increased  danger. 


Fig.  225. — Resection  of  inferior  maxilla.     (Farabeuf.) 


Prognosis  and  General  Consideration  of  Results. — Entirely  apart 
from  the  question  of  mortality,  which  is  necessarily  subject  to  the 
conditions  under  which  the  operations  for  resection  of  the  lower  jaw 
must  be  performed  and  which  in  most  cases  can  be  successfully  con- 
trolled, the  author's  experience  with  these  cases  leads  to  the  belief 
that  prognosis  is  usually  unfavorable  and  that  a  word  of  caution  is 
demanded. 

He  cannot  help  feeling  that  a  surgeon  ought  to  be  at  least  reason- 
ably sure  of  permanent  benefit  before  subjecting  a  patient  to  the 
postoperative  disadvantages  of  these  operations.     It  seems  as  though 


RESECTIONS  OF  THE  JAWS  393 

prolongation  of  life  that  is  to  be  continually  made  miserable  is  a 
questionable  benefit,  as  when  a  detached  ramus  is  drawn  inward  to 
irritate  the  tongue,  interfere  with  speech,  deglutition,  and  of  course 
mastication,  and  have  the  added  discomfort  of  dribbling  saliva  and 
deformity. 

Prosthetic  assistance  along  the  lines  suggested  by  the  illustrations 
sometunes  gives  much  satisfaction,  but  in  the  vast  majority  of  such 
cases  continued  movement  causes  loosening  of  crowns  or  even  of 
teeth,  and  removable  appliances  are  so  subject  to  change  in  the  form 
of  the  jaw  structures  that  permanent  comfort  is  often  an  unpossibility. 

Pictiu'es  of  misery  such  as  these  cases  present  are  not  soon  forgotten, 
especially  when  recurrent  growth  of  the  neoplasm  gives  evidence  of 
the  futility  of  the  suffering. 

That  through  misguided  judgment  many  lives  are  lost  which  might 
have  been  saved  had  more  radical  operations  been  performed  before 
advancing  malignant  disease  rendered  surgical  relief  unavailing  is  only 
too  true,  but,  on  the  other  hand,  many  jaws  have  been  resected  when 
the  affection  was  benign. 

The  author  was  once  called  upon  to  make  necessary  preoperative 
preparations  for  a  splint.  He  saw  the  case  for  the  first  time  as  the 
patient  was  about  to  be  taken  to  the  operating  room  for  complete 
resection  of  almost  the  entue  side  of  the  horizontal  portion  of  the 
mandible,  and  noted  that  the  condition  was,  in  fact,  a  simple  dento- 
alveolar  abscess,  not  a  sarcoma  as  previously  diagnosticated.  Later 
in  the  operatmg  room  he  was  able  to  prove  that  it  was  only  necessary 
to  extract  a  devitalized  lower  first  molar  and  do  a  small  curettement 
to  effect  a  ciue.  This  example  is,  of  course,  unusual,  but  it  neverthe- 
less points  the  way  to  great  need  of  caution. 

Resection  of  the  Upper  Jaw. — Defmition. — This  term  is  usually 
understood  to  mean  the  removal  of  the  superior  maxilla  upon  one  side, 
although  equally  applicable  when  both  superior  maxillse  are  removed. 
It  is  also  used  to  describe  partial  removal  of  this  bone.  Surgically 
this  should  not  be  confounded  with  removal  of  the  bone,  even  though 
included  almost  in  its  entirety  in  one  or  more  sequestra  of  necrosis, 
because  such  a  sequestrum  does  net  require  excision,  it  having  already 
separated  from  the  living  bone  except  for  the  attachments  of  soft 
tissues.  When  properly  performed,  removal  of  sequestra  is  a  com- 
paratively simple  operation  with  slight  danger  of  serious  damage,  and 
can  be  accomplished  from  ^ithm  the  mouth  without  external  incision. 
In  actual  resection  of  the  superior  maxilla  for  malignant  growths, 
however,  the  sm'gical  problems,  especially  with  regard  to  hemorrhage 
and  shock,  are  of  very  serious  character,  and  require  a  high  degree  of 
surgical  skill  at  the  time  of  operation,  as  for  the  preoperative  and  post- 
operative steps,  in  order  to  avoid  disaster. 

Forms  of  Resection. — 

Partial.  Temporary  or 

Complete.  Osteoplastic. 


394 


DISEASES  OF  BONE 


Partial  resection  is,  as  a  rule,  easily  performed  through  the  mouth. 
The  position  of  the  patient  and  the  instrumentation  are  the  same 
as  described  for  resection  of  the  lower  jaw.  Hemorrhage  in  these 
cases  can,  as  a  rule,  be  readily  controlled  by  packing  or  the  ligation 
of  small  vessels  at  the  wound  surface. 

Complete  Resection  of  the  Upper  Jaw. — The  principal  differences 
between  the  various  operations  for  complete  resection  of  the  superior 
maxilla  are  in  the  lines  of  external  incision  for  exposure  of  the  parts. 
Figs.  226,  227,  228  and  229  are  self-explanatory,  and  indicate  the 
most  commonly  used  method  of  gaining  access  to  the  bony  field  of 
operation.  Of  these,  Velpeau's  and  Langenbeck's  are  objectionable 
because  of  insufficient  exposure  of  the  parts  and  division  of  the 
branches  of  the  facial  nerve  with  corresponding  postoperative  deform- 
ity. Weber's  modification  of  Diffenbach's  incision  is  generally 
accepted  to  be  in  all  respects  the  most  advantageous  and  gives  com- 
plete freedom  in  uncovering  the  bone  surfaces.  It  avoids  the  division 
of  important  nerves  and  follows  lines  which  make  the  scar  as  little 
noticeable  as  possible. 


Velpeau's.  Langenbeck's.  Weber's.  Kocher's. 

Figs.  226,  227,  228  and  229. — Lines  of  incisions  for  resection  of  upper  jaw. 


Surgical  Steps. — After  the  soft  parts  have  been  dissected  from  the 
bone,  the  bleeding  vessels  clamped,  and  capillary  hemorrhage  checked 
by  dry  gauze  applied  with  pressure,  or  gauze  wrung  out  of  hot  water, 
the  periosteum  is  forced  back  from  the  floor  of  the  orbital  cavity  as 
far  as  the  sphenomaxillary  fissure,  and  the  eye-ball  is  protected  with  a 
flat  instrument  and  gently  forced  out  of  the  way.  A  curved  needle 
connected  with  the  Gigli  wire  saw  is  passed  into  the  fissure  and  out 
at  the  malar  fossa.  With  this  the  malar  bone  is  divided.  The  articu- 
lation of  the  upper  jaw  with  the  nasal  and  frontal  bones  is  then  cut 
with  bone  shears.  In  division  of  the  hard  palate  the  Gigli  saw  passed 
through  the  nose,  behind  through  the  palate  and  out  through  the 
mouth  may  be  used,  or  a  long  fissure  bur  in  the  dental  or  surgical 
engine  may  be  substituted  with  increased  rapidity  and  facility  in 
many  ways.  The  jaw  is  then  loosened,  grasped  with  bone  forceps, 
and  twisted  out.  A  large  gauze  pad  should  be  at  hand  to  quickly  pack 
the  wound  and  check  the  force  of  hemorrhage  (Figs.  230  and  231). 


RESECTIONS  OF  THE  JAWS 


395 


Osteoplastic  rxesecHons.— Osteoplastic  resections  of  portions  of  the 
upper  jaw  for  tcmi)orary  purposes  are  usually  performed  by  freenig 
a  sufficient  portion  of  the  proposed  section  to  admit  of  its  being  forced 


■■■  '% 


Fig    230. — Division  of  bone  in  resection  of  jaw.     (Von  Bergmann.) 


Fig.  231. — Resection  of  superior  maxilla.     (Farabeuf.) 


/ 


396  DISEASES  OF  BONE 

apart  from  the  body  of  the  bone.  This  is  done  in  such  a  manner  as 
to  allow  of  its  being  turned  back  in  a  flap  with  the  overlying  tissues. 
It  is  then  replaced  without  complete  destruction  of  the  surrounding 
periosteum.  Without  going  into  detailed  description  of  the  several 
operations  for  this  purpose,  such  as  devised  by  Langenbeck  for  expos- 
ing the  base  of  the  skull  through  the  mouth,  the  various  procedures 
for  reaching  the  Gasserian  ganglion  as  outlined  on  pages  269-272, 
and  other  less  justifiable  operations  for  removal  of  tumors  in  this 
way,  it  is  sufficient  to  say  that  the  external  incisions  for  these  resec- 
tions are  such  as  to  permit  satisfactory  exposure  of  the  division  of 
the  bone  which  is  to  be  resected.  Closure  of  the  skin  surfaces  in  all 
the  operations  upon  the  jaws  requiring  external  incision  should  be 
accomplished  with  care  to  avoid  so  far  as  possible  unsightly  scars. 
Exact  coaptation  with  fine  silk  or  horse-hair  sutures  is  required,  or 
the  subcuticular  suture  may  be  placed  to  give  the  perfect  approxi- 
mation that  is  desired.  When  there  is  extreme  exhaustion  imme- 
diately following  the  operation,  sutures  may  be  rapidly  inserted 
which  will  hold  the  tissues  in  fairly  good  approximation,  and  after 
there  has  been  recovery  from  shock  at  a  later  period,  more  per- 
fect adjustment  can  be  accomplished  in  the  parts  that  are  most 
noticeable. 

Resections  for  Cosmetic  Purposes  to  Correct  Deformities  of  the  Jaws. — 
Much  that  has  been  done  in  a  surgical  wa}^  in  this  direction  has  been 
ill-advised.  The  author  has  seen  a  number  of  cases  in  which  resec- 
tions of  the  lower  jaw  have  been  made  to  correct  prognathism  in 
which,  although  the  surgical  steps  have  been  skilfully  performed,  the 
defective  condition  might  better  have  been  corrected  by  orthodontic 
procedures.  The  surgeons  in  these  cases  had  evidently  not  realized 
that  it  was  the  upper  jaw  that  needed  widening  and  extension,  not 
the  lower  jaw  that  needed  reduction,  and  that  nasal,  facial  and  other 
results  were  associated  with  the  contracted  upper  jaw  which  would 
also  have  been  improved  by  treatment  of  the  maxillse  instead  of  the 
mandible.  There  are,  however,  conditions  of  malformation  and 
imperfect  occlusal  relation  of  the  jaws  which  call  for  surgical  inter- 
ference. This  may  be  of  such  nature  as  to  bring  about  complete 
readjustment,  or  for  the  purpose  of  facilitating  treatment  in  correction 
of  orthodontic  procedures. 

For  example  when  the  mandible  is  so  much  longer  by  actual  meas- 
urement from  the  angle  on  each  side  to  the  symphysis,  with  facial 
deformity  such  as  is  shown  in  Fig.  232,  the  operation  illustrated  in 
in  Fig.  234  is  indicated.  The  author's  method  in  the  treatment  of 
such  cases  is  to  place  casts  of  the  jaws  upon  an  articulation,  cut  out  a 
section  from  the  plaster  cast  corresponding  to  the  bone  to  be  removed. 
When  this  adjustment  is  perfected,  a  splint  with  bands  to  be  cemented 
to  the  teeth,  and  suitably  adjusted  nuts  and  screws  is  prepared.  This 
is  cemented  to  the  teeth  twenty-four  hours  before  the  bone  excision  is 


RESECTIONS  OF  THE  JAWS 


397 


performed.  When  the  section  of  the  jaw  has  been  removed  the  bone 
ends  are  brought  together  and  held  in  perfect  apposition  by  tightening 
the  nuts  on  the  apphance. 


Fig.  232  Fig.  233 

Figs.  232  and  233. — Casts  of  the  face  of  a  young  man,  for  whom  the  author  removed 
a  section  from  one  side  of  the  lower  jaw,  as  shown  in  Fig.  234.  This  picture  is  shown 
through  the  courtesy  of  Dr.  Joseph  Eby,  of  Atlanta,  Ga.,  who  made  the  cast. 


Fig.  234. — Drawing  showing  the  deformity  of  the  jaws  of  the  young  man,  a  cast  of 
whose  face  is  shown  in  Figs.  232  and  233.  The  dotted  line  indicates  where  the  second 
bicuspid  tooth  and  a  section  of  bone  completely  through  the  jaw  was  removed  by  the 
use  of  a  hand  engine  bur. 


398 


DISEASES  OF  BONE 


Let  no  one  who  values  his  peace  of  mind  ever  cut  through  a  jaw 
without  first  having  made  provision  for  its  retention  if  conditions 
make  such  preparation  possi})le. 

Section  to  Correct  Unilateral  Shortness  of  the  Mandible. — When  the 
deformity  is  exactly  o})posite  to  that  illustrated  in  Fig.  232,  as  when 
there  has  been  contraction  due  to  necrosis,  accidental  or  surgical 
injury,  or  maldevelopment  from  other  causes,  through  which  one 
side  of  the  mandible  is  shorter  than  the  other  with  tlie  chin  drawn  to 


Fig.  235. — Shows  drawing  of  the  jaws  as  they  were  in  the  cast  illustrated  in  Figs. 
232  and  234  after  removal  of  a  second  bicuspid  tooth  and  complete  resection  of  the  jaw, 
the  approximation  of  the  bone  ends  and  fixation  with  an  appliance  attached  with  metal 
bands  cemented  to  the  teeth  and  adjusted  by  a  nut  tightened  upon  a  thread  cut  in  the 
bar  of  the  appliance.  In  most  cases  the  metal  band  shown  attached  to  the  molar  next  to 
the  point  of  excision  would  be  better  attached  one  tooth  farther  back.  The  situation  of 
the  bands  must  necessarily  be  determined  by  the  condition  of  the  case. 

one  side  as  shown  in  Fig.  237,  a  similar  appliance  is  arranged  to  make 
extension  instead  of  contraction  after  the  jaw  has  been  resected  as 
shown  in  Fig.  23G.  Intra-oral  separation  is  made  preferably  between 
the  cuspid  and  first  bicuspid,  or  between  the  bicuspids,  with  care  to 
avoid  the  mental  foramen  and  its  vessels.  The  author  uses  a  fine 
straight  saw  which  can  be  passed  between  the  teeth,  and  by  retracting 
the  lips  can  usually  be  made  to  divide  the  jaw-bone  through  the  septum 
which  separates  the  roots,  without  serious  injury  to  the  pericementum. 


RESECTIONS  OF  THE  JAWS 


399 


Beyond  tliis  the  division  is  completed   with  dental  engine  burs, 
until  a  fracture  of  the  undivided  part  of  the  section  may  be  accom- 


FiG.  236. — Illustration  of  an  appliance  which  acts  as  a  splint  when  the  mandible 
is  diWded.  It  is  also  capable  of  exerting  pressure  when  the  nuts  are  turned  to  give 
extension  and  thereby  lengthens  the  jaw.  An  increased  length  of  one-half  inch  more 
on  one  side  may  thus  be  secured  with  comparatively  little  difficulty  by  an  intrabuccal 
operation.  If  one  inch  or  more  be  required  then  bone  grafting  through  an  external 
incision  is  required. 


Fig.  237. — Photograph  of  a  young  man  whose  jaw  was  very  much  one-sided,  with  a 
markedly  receding  chin,  for  whom  the  operation  illustrated  in  Fig.  236  was  performed. 
Approximately  one-half  inch  was  gained  on  the  left  side  of  the  mandible  by  this  method 
with  corresponding  improvement  in  his  appearance. 

plished.    This  leaves  at  least  a  portion  of  the  periostium  intact.    By 
turning  the  nuts  on  the  appliance  the  pressure  thus  exerted  may  be 


400 


DISEASES  OF  BONE 


made  to  extend  the  mandible  from  one-third  to  one-half  inch.  The 
appliance  ser^'es  as  a  splint  to  support  the  di\'ided  bones  until  bone 
repair  has  assured  the  permanence  of  the  result  (Fig.  237).  There 
should  be  no  external  scar  in  these  cases. 

If  conditions  are  unfavorable  for  the  intra-oral  operation,  as  when 
greater  extension  of  the  jaw  is  required,  bone  grafting  must  be  resorted 
to.  Dr.  Fred  H.  Albee,  of  New  York,  by  the  use  of  his  wonderfully 
accurate  bone-cutting  instruments  removes  a  section  of  bone  from  the 
tibia  and  grafts  it  between  the  ends  of  the  divided  mandible.  The 
section  removed  is  cut  in  such  form  as  to  favor  its  retention  and 
mortised  into  correspondingly  cut  receptacles  in  the  jaw-bone. 


Fig.  238  Fig.  239 

Figs.  238  and  239. — Radiographs,  showing  tumor  and  successful  bone  graft.  The 
tumor  was  removed  and  a  section  of  rib  grafted  into  the  jaw  by  Dr.  Judd,  of  the  Mayo 
Clinic. 


Dr.  Judd,  of  the  ]\Iayo  Clinic,  at  Rochester,  ]Minn.,  has  reported 
a  ver}^  successful  case  in  which  he  grafted  a  section  of  rib  to  replace 
bone  lost  in  the  excision  of  a  tumor  from  the  lower  jaw. 

The  external  operation  should  be  performed  with  care  not  to  enter 
the  buccal  cavity.  FVeedom  from  infection  is  absolutely  essential  to 
successful  bone  grafting.  The  bone  is  handled  entirely  with  instru- 
ments, even  gloved  hands  are  not  allowed  in  contact  with  the  graft. 
An  autograft  is  by  all  means  preferable  to  bone  taken  from  another 
individual,  and  animal  grafts  are  usually  useless.  The  protection  of 
the  periosteal  co^•ering  is  also  essential  to  the  best  success. 

In  deciding  between  these  t^-pes  of  operation  the  author's  experience 
in  the  following  case  may  be  of  interest.  The  retention  of  the  bone 
segments  following  an  operation  to  restore  the  jaw  of  a  young  girl  that 
was  badly  contracted  from  necrosis,  was  found  to  be  exceedingly 
difficult  and  discouraging  because  of  the  absence  of  lower  back  teeth 
on  that  side.  Nevertheless,  by  ligation  of  the  lower  to  the  upper  teeth, 
sufficient  retention  was  secured  to  give  an  impro\^ement  of  approxi- 


RESECTIONS  OF  THE  JAWS  401 

mately  one-half  inch.  lyuter  this  patient  went  to  the  late  Dr.  Murphy 
who  undertook  to  graft  bone  through  an  external  opening.  The  result 
was  loss  of  the  graft  from  necrosis,  a  bad  scar  following  the  slow  healing 
of  a  very  persistent  fistula  through  which  the  buccal  fluids  and  pus 
discharged.  The  skill  of  this  surgeon  was  world  renowned,  therefore 
the  warning  against  this  treatment  except  under  favorable  conditions 
is  the  more  entitled  to  consideration. 

Bilateral  Resection  for  the  Reduction  of  Prognathous  Lower  Jaws. — 
Blair  and  Angle  have  perfected  a  method  of  performing  a  submucous 
periosteal  operation  for  the  removal  of  a  section  upon  each  side  of  the 
jaw,  and  fixation  by  the  aid  of  a  splint  covering  the  crowns,  buccal 
and  lingual  surfaces  of  the  teeth,  made  in  three  sections  and  cemented 
before  the  operation  so  that  they  may  be  fastened  together  immediately 
upon  removal  of  the  bone  segments. 

Blair  believes  that  the  jaw  should  also  be  wired  near  the  lower 
border  to  give  additional  security.  Babcock  cuts  through  the  rami 
of  the  jaw,  slides  the  body  back,  and  fastens  it  in  this  position.  Harsha 
cuts  sections  from  the  angle  on  each  side,  and  thus  accomplishes  the 
necessary  shortening. 

The  author  has  seen  one  of  Babcock's  cases  in  which  the  result  was 
perfect  insofar  as  retraction  was  concerned,  and  Harsha's  models  and 
illustrations  leave  no  doubt  as  to  the  success  of  his  method  in  this 
respect ;  but  in  both  of  these  cases  it  appeared  that  better  results  could 
probably  have  been  attained  by  enlargement  of  the  upper  jaw  instead 
of  shortening  the  lower,  and  with  a  distinct  benefit  to  respiration  and 
health  by  such  expansion. 

Malocclusion  with  the  Molars  in  Contact  and  a  Wide  Separation  between 
the  Anterior  Teeth. — This  defect  which  not  only  affects  the  facial 
appearance,  but  the  speech  also,  is  often  very  marked.  Correction  in 
young  children  is  best  accomplished  by  orthodontic  procedures,  the 
use  of  a  skull  cap,  with  chin  attachment,  or  intermaxillary  rubbers 
attached  to  appliances  adjusted  to  the  teeth  to  hold  and  regulate  the 
pressure,  will  often  work  wonders  in  these  cases.  A  large  variety  of 
appliances  and  methods  for  this  purpose  have  been  devised  by  many 
orthodontists. 

In  adults  surgical  treatment  may  be  required.  The  deformity  may 
then  be  corrected  by  the  extraction  of  a  bicuspid  tooth  on  each  side, 
the  removal  of  a  V-shaped  section  from  the  jaw,  forcing  the  chin 
upward  to  make  a  green-stick  fracture  of  the  lower  border  of  the  jaw, 
and  holding  the  parts  with  an  appliance  similar  to  the  one  shown  in 
Fig.  235.  The  likelihood  of  shortening  the  jaw  is  an  objection  to  the 
operation.  Except  for  the  external  scar,  the  author  believes  that  this 
might  be  accomplished  more  successfully  by  cutting  through  the  lower 
border  of  the  jaw,  after  making  an  incision  through  the  skin,  separating 
the  intervening  tissues  and  the  periosteum,  to  avoid  mouth  infection, 
then  forcing  the  anterior  teeth  into  contact  and  holding  them  in  posi- 
tion with  interdental  ligatures  from  jaw  to  jaw. 
26 


402  DISEASES  OF  BONE 

The  Surgical  Correction  of  Mandibular  Deformities  Due  to  Tumor 
Growths. — \Mieii  the  outline  of  the  lower  jaw  has  been  deformed  by 
tumor  growth,  much  may  be  done  by  careful  separation  of  the  over- 
lying periosteum,  and  the  removal  of  the  redundant  bone  structures 
sufficiently  to  restore  s\Tnmetrical  outlines.  The  periosteum  is  then 
replaced.  Notwithstanding  the  unavoidable  oral  infectious  influences 
the  results  in  such  cases  are  usually  gratifying. 

Preservation  of  the  periosteum,  and  of  the  form  of  the  outline  of  the 
jaw  is  important  in  these  cases  (Figs.  259  and  291,  pp.  440  and  467). 

Eeceding  Chin. — Receding  chin  may  be  due  to  malposition  of  the 
mandible  to  attested  mandibular  development  or  to  a  combination  of 
both.  Jumping  the  bite,  by  orthodontic  processes  whereby  the  occlusal 
relation  of  the  jaws  is  changed  in  such  manner  as  to  bring  the  mandible 
forward,  is  generally  and  successfully  accomplished  for  children. 
Steadily  applied  pressure  with  appliances  adjusted  to  the  teeth  may 
also  stimulate  gro^\'th.  The  jaw  may  be  lengthened  by  bone  grafting 
or  the  chin  may  be  made  more  prominent  by  transplanting  fat,  or 
cartilage  to  give  it  an  appearance  of  more  harmonious  prominence. 
The  author  does  not  believe  in  the  use  of  paraffin  injection  when 
surgical  transplantation  of  tissue  may  be  made  to  serve  the  purpose. 

Operative  Dangers  and  Methods  of  Avoiding  Them. — Hemorrhage. — 
Ligation  of  the  external  carotid  is  usually  required,  and,  as  a  rule, 
is  sufficient  to  avoid  dangerous  loss  of  blood.  In  more  or  less  rare 
instances  compression  of  the  common  carotid  with  temporary  ligature 
or  clamp  may  be  required.  Because  of  the  effect  upon  the  brain, 
permanent  ligation  of  this  vessel  should  be  avoided.  Dawbarn  recom- 
mends reduction  of  the  flow  of  blood  by  temporary  bands  made  of 
small  rubber  tubing  tied  close  to  the  shoulders  and  the  thighs  and 
drawn  sufficiently  to  impede  but  not  completely  suppress  circulation 
in  the  extremities.  Trile  says:  "Permanent  closure  of  the  common 
carotid,  and  on  account  of  the  high  percentage  of  cerebral  softening 
in  the  cancer  period  of  life,  should  be  avoided.  Permanent  closure  of 
the  external  carotid,  while  it  is  not  attended  by  the  risk,  carries  with  it 
approximately  2  per  cent,  mortality  rate  from  washing  away  of  the 
thrombus  of  the  ligatured  stump,  causing  cerebral  embolism." 

A  very  large  element  of  danger  lies  in  the  inspiration  of  blood  or  the 
secondary  effects  of  inspiration,  diseases  of  the  air  passages  due  to 
wound  infection,  bronchitis,  and  affections  of  the  lungs,  which  are 
said  to  have  been  responsible  for  more  than  one-half  of  the  deaths 
following  this  operation. 

The  Rose  position  reduces  the  likelihood  of  blood  being  inspired, 
but  this  position  is  not  suitable  for  the  performance  of  the  operation. 
With  the  shoulders  raised  and  the  head  tipped  back  as  previously 
described  (page  74),  practically  the  same  effect  is  secured  as  with  the 
Rose  position,  with  the  head  hanging  over  the  end  of  the  table  but 
with  the  parts  in  more  favorable  position  for  operation.  Crile,  Warren, 
and  others  prefer  the  patient  with  head  raised,  and  body  in  a  semi- 


RESECTIONS  OF  THE  JAWS  403 

recumbent  position  or  in  a  sitting  position.  Crile  uses  his  pneumatic 
suit  to  overcome  the  effect  of  the  raised  position  of  the  body.  A  still 
safer  plan  is  to  follow  the  method  of  Bennet  as  modified  by  Crile,  who 
passes  two  rubber  tubes  through  the  nose  into  the  pharynx  to  a  point 
opposite  the  epiglottis,  and  then  packs  the  pharynx  with  gauze.  A 
T-tube  is  attached  at  the  nasal  entrance  and  the  vapor  of  the  anesthetic 
is  given  through  the  tube.  In  this  way  there  is  absolute  certainty  of 
preventing  blood  from  reaching  either  the  lungs  or  the  stomach. 

The  performance  of  a  prophylactic  tracheotomy  is  not  required  when 
these  precautions  are  taken,  and  is  objectionable  for  many  reasons, 
but  chiefly  because  the  patient  cannot  expel  mucus  and  secretions, 
the  effect  of  which  upon  the  phar\TLS  and  lungs  is  a  serious  menace. 
Martin  reports  28  per  cent,  of  deaths  from  this  cause. 

Crile  has  called  attention  to  the  necessity  of  the  sparing  use  of 
anesthetics,  and  in  grave  cases  favors  the  use  of  nitrous  oxide  and 
oxA'gen  followed  by  ether  in  the  smallest  possible  quantity  consistent 
vrith.  avoidance  of  shock. 

When  the  phar^Tix  is  not  packed  with  gauze  it  must  be  remembered 
that  complete  abolishment  of  the  reflexes  increases  the  danger  of  blood 
inspiration.  .'!-ufficient  insensibility  to  pain  and  unconsciousness  can 
be  maintained  while  the  reflexes  are  yet  suflBciently  active  to  cause  the 
blood  to  be  swallowed  instead  of  allo'^ing  it  to  enter  the  bronchi  and 
lungs.  All  other  considerations  pertaining  to  preparation  of  the  patient 
for  grave  operation  as  well  as  avoidance  of  unnecessary  loss  of  time  in 
its  performance  should  be  considered  imperative. 

Shock  and  Collapse.- — In  these  extensive  operations  prevention  of 
shock  and  collapse  may  be  eflFectively  accomplished.  The  important 
shock-producing  factors  are:  The  number  and  intensity  of  surgical 
contacts,  as  forcible  retraction,  ^'igo^ous  and  repeated  sponging,  blunt 
dissection,  tearing,  etc.;  loss  of  blood;  mismanaged  anesthesia;  and  the 
duration  of  the  operation.  The  principal  factors  causing  collapse  are: 
Interference  ^\"ith  the  tnnik  and  certain  branches  and  terminals  of  the 
vagus,  excessive  hemorrhage,  air  emboli,  and  anesthetic  accidents. 

The  Removal  of  Both  Superior  Maxillae. — The  steps  in  removal  of 
both  superior  maxillge  are  identical  with  those  already  described  for 
unilateral  resection,  except  that  division  of  the  palate  may  not  be 
required.  It  would  seem  that  this  operation  could  never  be  justifiable 
under  any  circumstances,  yet  it  was  performed  for  the  first  time  by 
He^■felder  in  1841,^  and  has  been  done  since  then  by  a  number  of 
surgeons. 

Postoperative  Treatment. — The  author  prefers  dry  sterile  gauze 
laid  over  the  skin  surface  and  held  in  position  with  strips  of  adhesive 
plaster.  Dusting  powders  he  has  almost  entirely  discarded  because 
after  their  immediate  eftect  is  over  the  powder  becomes  clogged  about 
the  stitches  and  renders  their  being  kept  clean  more  difficult;  the  dry 

1  Von  Bergmann:  System  of  Practical  Surge^J^  i,  730. 


404 


DISEASES  OF  BONE 


gauze,  on  the  other  hand,  absorbs  moisture.  If  there  should  be  infection 
or  secretions  of  the  mouth  which  work  through  to  the  skin  surface  at 
any  points,  they  are  easily  and  directly  controlled  by  touching  occa- 
sionally with  cotton-wrapped  applicators  dipped  in  dioxogen.  Gauze 
packing  \\'ithin  the  mouth  should  be  as  directed  (page  385),  and  the 
same  treatment  of  the  mouth  followed  with  regard  to  the  use  of  anti- 
septic and  cleansing  solutions.  Rectal  nourishment  must  be  continued 
until  such  time  as  it  may  be  possible  to  give  liquids  satisfactorily  by 
mouth.  With  care  to  avoid  infection  this  may  usually  be  done  almost 
from  the  beginning,  but  is  sometimes  a  matter  of  serious  difficulty. 
When  the  wound  is  healed,  deformit\'  ma^",  to  a  considerable  extent,  be 


Fig.  240. — Appliance  made  by  Dr.  Jernigan  in  case  of  removal  to  the  left  upper  maxilla. 

overcome  and  usefulness  of  the  mouth  restored  by  an  artificial  denture, 
which  in  the  hands  of  a  skilful  dentist  can  be  made  of  vulcanite  and 
sometimes  with  metal.  Fig.  240  shows  an  appliance  made  by  Dr. 
George  F.  Jernigan,  of  New  York,  which  was  successfully  worn  for 
several  years.  It  decreased  both  deformity  and  discomfort  in  a  con- 
siderable measure,  for  a  man  in  whose  case  the  upper  maxilla  on  the 
left  side  had  been  comjjletely  removed. 

Prognosis  and  General  Consideration. — ^Mortality  reports  vary  con- 
siderably, as  may  be  seen  by  the  following  table: 


aer  of  cas.es. 

Years. 

606 

1827  to  187.3 

158 

1870  to  1897 

108 

Recent  years 

230 

Recent  years 

12  (personal) 

Recent  j^ears 

Mortality  rate. 

18.4  per  cent. 

21.. 5 

30.0 

14.0 

16.0 

20.8 


Reported  by. 
Rabe. 
Kronlein. 
Butlin. 
Bryant. 1 
F.S.  Eve. 
Kronlein. 


It  will  be  seen  from  the  foregoing  table  that  the  results  of  these 
operations  are  determined  by  a  wide  range  of  conditions  not  only 


'  Joseph  Bryant:  Ann.  Surg.,  May,  1908. 


RESECTIONS  OF  THE  JAWS 


405 


pertaining  to  the  technic  of  the  operation,  but  to  those  also  under 
which  they  are  performed.  In  this  relation  the  character  and  eftect 
of  neoplasms  is  of  vital  importance.  This  feature  is  discussed  in 
consideration  of  tumors  (p.  431). 


■■\   ."J' 


Fig.  241 


Fig.  242 

Figs.  241  and  242.— Surgical  anatomy  of  the  neck;  ligation  of  the  carotid,  lingual  and 

facial  arteries.     (Bernard  and  Huette.) 

Exposure  of  Arteries.— In  view  of  the  fact  that  it  may  become  neces- 
sary to  expose  the  carotids,  the  lingual,  or  the  facial  arteries  to  control 
hemorrhage  in  emergency  incidental  to  operations  upon  the  mouth 
and  jaws;  as  a  preoperative  safeguard  in  extensive  operations;  for 


406  DISEASES  OF  BONE 

temporary  occlusion  by  provisional  ligation  or  the  use  of  Crile's  clamps; 
and  excision  of  a  section  for  the  purpose  of  cutting  off  the  circulation 
of  certain  parts  to  check  the  progress  of  inoperable  cancers  of  the 
tongue,  face,  and  jaws,  as  recommended  by  Dawbarn,  the  following 
brief  description  is  given  without  attempt  to  include  the  ligation  of 
the  facial  vessels  not  directly  connected  with  the  operative  field. 

The  Common  Carotid. — ^This  vessel  divides  at  the  level  of  the  thyroid 
prominence,  and  may  be  exposed  by  an  incision  of  10  cm.  in  length 
along  the  anterior  border  of  the  sternomastoid  at  its  central  portion, 
with  the  sternomastoid  drawn  outward  and  the  other  muscles  inward. 
The  artery  is  recognized  by  its  pulsation.  The  sheath  is  opened  and 
the  suture  passed  with  an  aneurysm  or  artery  needle  from  within  out- 
ward, with  care  to  avoid  the  descendens  noni.  The  internal  jugular 
must  be  carefully  avoided  and  retracted. 

The  External  Carotid. — Exposure  of  this  artery  may  be  effected  by 
an  incision  from  the  angle  of  the  jaw  to  the  level  of  the  cricoid  cartilage 
along  the  anterior  border  of  the  sternomastoid.  This  muscle  must  be 
retracted  outward.  The  posterior  belly  of  the  digastric  and  the  hypo- 
glossal nerve  are  avoided.  The  artery  will  be  found  opposite  to  the 
tip  of  the  great  cornu  of  the  hyoid,  and  the  superior  laryngeal  nerve 
which  passes  behind  the  vessel  must  also  be  carefully  avoided. 

The  Internal  Carotid. — This  artery  may  be  exposed  at  the  point 
where  it  lies  to  the  outside  and  back  of  the  external  carotid  through 
the  same  incision  by  which  the  external  carotid  is  exposed.  The 
external  branch  is  drawn  inward  and  the  digastric  upward  with  care 
in  passing  the  needle  to  avoid  the  jugular  and  the  vagus. 

The  Lingual  Artery. — An  incision  is  made  2  cm.  above  the  hyoid 
parallel  with  it  from  the  middle  line  almost  to  the  angle  of  the  jaw. 
The  submaxillary  gland  thus  exposed  is  retracted,  the  fascia  divided, 
and  the  posterior  border  of  the  mylohyoid  exposed.  The  digastric 
tendon  is  then  drawn  up^^■ard  and  the  hypojrlossal  nerve  brought 
into  view  with  the  artery  line  behind  it.  The  hyoglossus  must  be 
divided  by  a  short  incision  to  reach  the  vessel.  Injury  to  the  nerve 
must  be  avoided. 

The  Facial  Artery. — This  is  easily  exposed  at  the  margin  of  the 
lower  jaw  in  front  of  the  angle,  or  it  may  be  tied  lower  doA\n  through 
similar  incision  to  that  used  for  the  exposure  of  the  external  carotid 
(Figs.  241  and  242). 


CHAPTER    VII. 
DISEASES  OF  THE  GLANDS. 

DISEASES  OF  THE  SALIVARY  GLANDS. 

The  Pathological  Indications  of  Saliva. — During  recent  years 
Michaels  and  Kirk  have  done  much  to  bring  about  an  understanding 
of  the  possibilities  of  saliva  as  a  valuable  means  of  diagnosis.  In 
opposition  to  the  theories  of  these  writers  it  has  been  urged  that  the 
so-called  saliva  of  the  mouth  is,  after  all,  a  mixed  secretion  of  saliva, 
bacteria,  food  products,  ferments,  etc.;  that  saliva,  moreover,  is  a 
secretion  and  not  an  excretion,  and  that  therefore  its  indications  would 
not  be  diagnostic  of  pathological  states  as  are  the  urinary  and  other 
excretions.  Nevertheless,  colorimetric  and  qualitative  examination  of 
saliva  is  gradually  receiving  recognition  as  means  of  detecting  certain 
expressions  of  disease. 

More  recently  Roger,^  Simon,^  Le  Roy,'''  Fenwick,^  and  other  investi- 
gators have  given  valuable  evidence  that  saliva  has  an  important 
pathological  relation  to  general  as  well  as  local  affections. 

Congenital  Defects  of  the  Salivary  Glands. — Anomalous  develop- 
ment is  infrequent,  but  a  sufficient  number  of  cases  have  been  reported 
to  indicate  that  such  anomalies  must  be  borne  in  mind,  as  they  some- 
times are  an  important  factor  in  diagnosis.  Misplaced  or  absent 
salivary  glands  have  been  reported.  Gruber  found  both  submaxillary 
glands  absent  in  one  case,  and  in  another  the  parotid  gland  appeared 
in  the  situation  of  the  accessory  parotid  at  the  posterior  border  of 
the  buccal  cavity.  Turner  reports  a  case  in  which  the  submaxillary 
glands  were  found  on  the  dorsal  surface  of  the  mylohyoid  close  to  the 
sublingual  glands  instead  of  the  digastric  triangle.  The  orifices  of 
Wharton's  and  Steno's  ducts  frequently  vary.  Occasionally  there  is 
atresia  of  these  ducts  or  the  openings  may  be  exceedingly  small  or 
double  instead  of  single.  Cases  of  congenital  salivary  fistula  have  been 
reported  by  Gherini,  Roser,  and  Konig.^ 

Symptoms.^ — The  symptoms  are  usually  indicated  by  alterations 
in  the  anatomical  appearance.  With  congenital  absence  of  an  opening 
through  the  duct  ranula  may  result,  or  unusual  situations  of  the 
orifices  may  lead  to  exposure  and  irritation,  thus  causing  pathological 
disturbance,  displacement,  or  interference  with  nerves,  bloodvessels, 
or  other  structure. 

1  Roger:  Soc.  de  Bio].,  1907. 

2  Simon:  Jour,  de  Physiol,  et  de  Pathol.,  March,  1907. 

3  Le  Roy:  New  York  Med.  Jour.,  March  7,  1908. 

*  Fenwick:  Pract.  Med.  Series,  1908,  vol.  vi.  General  Surgery,  p.  133. 

*  Kiittner:  Von  Bergmann's  System  of  Practical  Surgery,  p.  G07. 

(407) 


408  DISEASES  OF  THE  GLANDS 

Treatment.- — In  the  rare  instances  when  treatment  is  required,  the 
therapeutic  and  surgical  methods  necessarily  are  indicated  by  existing 
symptoms. 

Injuries  of  the  Salivary  Glands.— The  sublingual  and  submaxillary 
glands  are  so  situated  as  to  be  more  or  less  protected  from  traumatic 
injury.  The  parotids  and  their  ducts,  however,  are  more  exposed  to 
trauma,  hence  it  naturally  follows  that  these  structures  most  frequently 
require  treatment. 

Etiology. — The  injury  may  be  surgical,  or  be  caused  by  stab  or 
gunshot  wounds  or  accidental  laceration  of  the  glands  by  foreign 
substances  forced  through  the  floor  of  the  mouth  or  external  surfaces, 
and  traumatism,  particularly  in  the  parotid  region. 

Prognosis. — Favorable  in  the  absence  of  serious  complication  by 
infection  or  extensive  tissue  destruction. 

Treatment.^Clean  surgical  \\ounds  heal  readily  and  require  no  spe- 
cial treatment  other  than  careful  suturing  of  the  deep  and  superficial 
structures  to  favor  immediate  union  and  to  prevent  the  formation  of 
salivary  fistula.  In  other  injuries  the  chief  difficulties  lie  in  the  forcing 
of  infection  into  the  substance  of  the  gland  and  the  destruction  of  tissue 
which  makes  accurate  closure  difficult  and  therefore  favors  the  forma- 
tion of  fistula.  If  temporarily  unavoidable,  this  can  be  corrected  at  a 
later  operation.  Fixation  of  the  jaws  for  several  days  by  a  bandage 
which  should  also  be  so  adjusted  as  to  make  firm  pressure  over  the 
gland,  is  of  aid  in  preventing  the  formation  of  fistula;  food  which 
unduly  excites  salivary  secretion  should  be  restricted  to  give  sufficient 
time  for  healing  processes  to  take  place. 

Injuries  of  the  Ducts. — Under  unusual  conditions  the  ducts  of  any 
of  the  salivary  glands  may  suffer  traumatic  injury.  Steno's  duct, 
extending  from  the  parotid  gland  to  a  point  close  to  the  region  of  the 
second  molar  tooth  in  line  with  the  lobule  of  the  ear,  and  the  angle  of 
the  vermilion  border  of  the  upper  lip,  is  much  more  exposed  than  the 
other  ducts.  It  lies  across  the  region  of  the  face  most  subject  to  injury. 
It  is  an  important  factor  in  the  selection  of  many  surgical  operations 
requiring  incision  through  the  cheek;  even  with  the  greatest  care  it 
cannot  always  be  avoided.  Vertical  wounds  of  the  face  are  likely  to 
cause  its  complete  division.  Severe  blows  upon  the  cheek  have  been 
known  to  cause  its  rupture  without  division  of  the  overlying  tissues. 

Symptoms. — Flow  of  saliva  from  the  duct  into  the  wound  may  be 
distinguished  when  hemorrhage  is  checked.  A  sound  passed  through 
the  orifice  of  the  duct  within  the  mouth  appears  at  the  point  of 
injury. 

Treatment. — The  ends  of  the  divided  duct  should  be  carefully 
approximated  and  fixed  with  fine  catgut  sutures  which  should  not 
enter  the  lumen  of  the  duct.  Closure  of  the  wound  so  as  to  favor 
exact  approximation  usually  gives  prompt  and  perfect  union.  In  the 
absence  of  such  care  or  when  perfect  coaptation  is  not  possible,  salivary 
fistula  usually  results.    Salivary  secretion  must  be  checked  by  fixation 


DISEASES  OF  THE  SALIVARY  GLANDS  409 

of  the  lower  jjnv  and  eompression  of  the  gland  with  a  bandage  as 
previously  described. 

Salivary  Fistula. — Salivary  fistula  is  an  abnormal  opening  through 
which  sali\  a  reaches  the  surface. 

Varieties. — The  principal  varieties  are  salivary  glaiid  fistulse  and 
salivary  duct  fistulie. 

External  fistula,  which  is  the  only  one  requiring  surgical  treat- 
ment, is  chiefly  confined  to  the  parotid  gland  and  the  duct  of  Steno. 

Etiology. — Traumatic  injury  is  the  most  frequent  etiological  factor, 
but  fistuhne  may  also  result  from  abscess  or  ulcerative  processes  due  to 
pyogenic  microorganisms  or  infectious  diseases,  such  as  tuberculosis 
and  syphilis,  or  from  tissue  destruction  by  carcinoma.  The  origin  may 
be  within  the  gland  or  result  from  involvement  of  the  glandular  struc- 
ture during  the  progress  of  disease  from  surrounding  tissues.  Fistulse 
may  also  be  congenital. 

Symptoms. — Whether  the  fistula  be  connected  with  the  gland  or 
its  duct,  the  characteristic  symptom  is  discharge  of  saliva  which 
appears  through  an  opening  upon  the  external  sm-face.  The  saliva 
is  annoying  and  usually  causes  more  or  less  excoriation  of  the  skin 
surface.  If  the  flow  is  slight  and  of  a  watery  character,  a  fistula  of  the 
gland  is  indicated  because  only  a  portion  of  the  glandular  secretion  is 
drained.  When  the  flow  is  abundant,  the  probability  is  strongly  in 
favor  of  a  fistula  of  the  duct.  Fistula  anterior  to  the  margin  of  the 
masseter  is  usually  one  of  the  duct.  If  the  fistula  is  connected  with 
Steno's  duct,  a  sound  may  sometimes  be  passed  for  a  considerable 
distance,  but  this  is  usually  impossible  in  fistula  of  the  gland. 

Differential  Diagnosis. — 

DUCT.  GLAND. 

Excessive  flow  of  saliva.  Moderate  amount  of  saliva. 

Opening  sometimes  anterior  to  margin  Rarely  so  far  forward  as  the  anterior 

of  the  masseter.  margin  of  the  masseter. 

Probe  can  be  passed  into  the  tract  for  Probe   penetration   only   a   short   dis- 

a  considerable  distance.  tance. 

Treatment. — Salivary  Gland  Fistula. — This  form  may  sometimes  be 
closed  by  repeated  cauterization  with  nitrate  of  silver  or  the  galvano- 
cautery,  and  such  treatment  is  recommended  as  a  first  step.  If  unsuc- 
cessful, the  borders  of  the  wound  should  be  freshened,  the  parts  brought 
into  immediate  contact  if  possible,  and  carefully  sutured.  Pressure 
with  a  bandage,  restriction  of  salivary  flow  by  dieting,  and  fixation  of 
the  jaws  must  be  continued  during  several  days  to  permit  union  of  the 
parts. 

Salivary  Duct  Fistula. — Temporary  duct  fistula  should  be  given 
opportunity  to  heal  spontaneously  and  efforts  should  be  made  to 
preserve  the  integrity  of  the  duct. 

Permanent  duct  fistula  may  be  treated  by:  (1)  Restriction  of  the 
normal  outflow  of  saliva  through  the  duct.     (2)  The  establishment 


410 


DISEASES  OF  THE  GLANDS 


of  an  internal  opening  with  closure  of  the  external  one.     (3)  Oblitera- 
tion or  removal  of  the  gland. 

Of  these,  the  simplest  and  most  practical  is  the  establishment  of 
an  internal  opening  and  closure  of  the  external  fistula.  Exposure  at 
the  duct,  excision  of  the  scar,  and  closure  by  fine  catgut  sutures,  as 
recommended  by  Nicoladoni,  without  recurrence  of  occlusion  of  the 
duct,  are  possible,  and  obliteration  of  the  gland  may  be  accomplished  by 
compression,  ligation  of  the  central  end  of  the  duct,  or  removal  of  a 
part  or  all  of  the  gland.  The  former  method,  however,  appears  too 
difficult  and  uncertain,  and  the  latter,  it  is  generally  admitted,  should 
only  be  attempted  as  a  last  resort.  The  establishment  of  an  internal 
opening  and  closure  of  the  external  fistula  may  be  accomplished  by 
single  puncture  ^^•ith  a  trocar  to  establish  flow  of  saliva  into  the  mouth. 
This  opening  must  be  maintained  until  healing  processes  have  been 
completed,  afterward  closure  of  the  external  fistula  may  take  place 
spontaneously  or  be  accomplished  by  plastic  operation. 

In  spite  of  efforts  to  preserve  a  single  opening  its  closure  is  always 
a  menace.  A  far  better  and  simpler  method,  accordingly  is  to  pass  a 
suture  behind  the  point  of  occlusion  of  the 
duct,  to  tie  the  suture  loosely  and  allow  it  to 
remain  until  the  two  openings  are  permanently 
established.  When,  as  frequently,  the  buccal 
portion  of  the  duct  is  occluded,  the  suture  may 
be  passed  by  a  curved  needle  in  the  mouth; 
but  when  the  masseteric  division  of  the  duct 
is  affected,  it  is  better  to  make  two  openings 
with  a  trocar  through  the  external  fistula  and 
to  pass  the  two  ends  of  a  wire  to  form  a  loop, 
the  ends  being  loosely  twisted  within  the  mouth, 
as  shown  in  Fig.  243.  This  is  better  than  silk 
or  other  suture  material,  because  it  does  not 
absorb  secretion  and  is  not  likely  to  cause 
infection;  moreover,  such  a  loose  wire  loop  is 
moved  sufficiently  by  muscular  activity  to 
prevent  the  openings  from  closing. 

Foreign  Bodies. — Etiology. — Both  Wharton's 

and  Steno's  ducts  are  occasionally  invaded  by 

foreign  bodies  such  as  fish-bones,  tooth-brush 

bristles,  splinters  of  \\'ood  from  toothpicks,  fruit 

seeds,  and  other  objects  sufficiently  small  to  enter  the  orifices  of  the 

ducts;  projectiles  may  sometimes  be  driven  into  and  lodged  within  the 

gland  structure. 

Symptoms. — There  may  be  sharp  pain  at  the  moment  of  entrance, 
followed  by  swelling,  more  general  pain  continues,  and  other  dis- 
tressing symptoms  are  occasioned  by  occlusion  of  the  duct  and  inter- 
ference with  normal  salivary  excretion.  The  distressing  symptoms  may 
disappear  and  recur  from  time  to  time  until  the  foreign  body  is  removed. 


Fig.  243.  —  Operation 
for  salivary  duct  fistula 
according  to  Deguise. 
(Duplaj'-Reclus.) 


DISEASES  OF  THE  SALIVARY  GLANDS  411 

Sometimes  little  discomfort  is  felt  until  in  the  course  of  time  the  body 
becomes  surrounded  by  deposits  of  salivary  calculus,  and  in  this  way 
leads  to  the  formation  of  salivary  stone.  If  the  foreign  body  is  not 
forced  out  by  inflammatory  processes  or  removed,  symptoms  of  chronic 
inflammation  flevelop  with  discharge  of  i)us  within  the  gland,  and  as 
a  result  local  and  general  symptoms  of  serious  character  may  develop. 

Diagnosis. — If  the  object  cannot  be  seen  or  felt  from  the  surface  it 
may  be  located  by  passing  a  probe  into  the  duct.  When  this  is  imprac- 
ticable, on  account  of  the  swelling  of  acute  inflammation,  the  presence 
of  such  a  body  can  best  be  determined  by  a  radiograph. 

Treatment. — Remove  the  foreign  body.  If  superficially  situated  its 
extraction  is  easily  accomplished,  especially  if  pressure  can  be  applied 
to  force  it  out  of  the  duct.  When  this  is  impossible  an  incision  is 
required  for  its  exposure.  Care  must  be  exercised  during  healing  of 
the  wound  to  prevent  occlusion  of  the  duct.  Other  treatment  must 
be  directed  toward  relief  of  inflammation  and  abscess  if  such  conditions 
be  present. 

Salivary  Stones;  Sialolithiasis. — The  formation  of  salivary  stones 
occurs  somewhat  rarely  and  affects  the  salivary  glands  and  their  ducts 
in  approximately  the  following  order  :^ 


Wharton's  duct 
Submaxillary  gland 


61.4  per  cent. 


Steno's  duct  \  ^q  ^  ^ 

Parotid  gland  /  ^'^  ^^^  ^^''^• 

Sublingual  glands  1 13.2  per  cent, 

and  ducts  J  ^ 

Concretions  within  the  salivary  glands  are  found  most  frequently 
in  middle  life  and  among  men  more  often  than  women,  although 
children  may  occasionally  be  affected,  and  a  congenital  case  has  been 
reported  by  Burdel. 

Etiology.— A  small  particle  of  calculus  from  about  the  necks  of  teeth 
may  find  entrance  into  the  duct  of  a  gland  and  act  as  a  foreign  body 
or  become  the  nucleus  for  the  formation  of  a  salivary  stone.  Other 
foreign  substances  may  act  in  a  similar  manner.  The  presence  of 
masses  of  bacteria  in  the  interior  of  these  concretions  of  lime  salts, 
however,  demonstrates  that  in  the  large  majority  of  cases  bacteria  are 
the  primary  causes. 

Ssrmptoms. — Salivary  stones  are  principally  composed  of  phosphate 
and  carbonate  of  calcium,  and  vary  greatly  in  size,  form,  color,  and 
number.  Usually  they  are  single  and  somewhat  elongated,  especially 
if  situated  in  the  ducts.    Those  within  the  glands  are  much  more  irreg- 

1  Statistics  of  Czygan,  Buchwald  and  Wenzel,  and  Kiittner.  Von  Bergmann's  System 
of  Practical  Surgery,  i,  619. 


412  DISEASES  OF  THE  GLANDS 

ular.  They  vary  in  size  from  tiny  grains  of  sand  to  stones  weighing 
20  grams  or  more.  The  symptoms  are  those  of  foreign  bodies,  such 
as  dilatation  of  the  duct,  inflammation,  ulceration,  and  suppuration, 
abscesses,  salivary  fistula,  etc.  The  history  usually  shows  more  or  less 
gradually  increasing  disturbance,  with  appearance  and  disappearance 
of  acute  symptoms,  due  to  salivary  stasis  and  infection.  These  aie 
sometimes  very  painful.  Chronic  discharge  of  pus  (pyorrhea  salivalis) 
from  the  duct  is  sometimes  almost  the  only  noticeable  symptom. 

Diagnosis. — If  situated  in  the  duct,  the  stone  can  usually  be  felt 
with  the  finger  or  a  probe.  Usually  the  fistulous  tract  is  sufficiently 
clear  to  be  followed  into  the  gland  also.  When  this  cannot  be  done  the 
sublingual  gland  may  be  palpated  with  one  finger  in  the  floor  of  the 
mouth  and  the  other  upon  the  outside,  and  the  hard  mass  thus  dis- 
tinguished. When  the  stone  cannot  be  felt  with  a  probe,  a  radiograph 
must  be  relied  upon.  Ludwig's  angina,  phlegmonous  angina,  alveolar 
periostitis,  dento-alveolar  abscess,  lymph  nodes,  inflammatory  tumors, 
tuberculosis,  syphilis,  and  actinomycosis  must  be  difl^erentiated  in 
diagnosis.  These  may  be  recognized  by  their  special  diagnostic  indica- 
tions, and  the  demonstration  of  the  salivary  stone  either  with  a  probe 
or  the  Roentgen  rays  completes  the  diagnosis. 

Treatment. — Whenever  possible,  salivary  stones  should  be  removed 
through  the  mouth.  When  situated  deep  within  the  parotid  or  sub-" 
maxillary  glands  or  when  they  have  an  external  fistula  in  direct 
communication  with  its  surrounding  abscesses,  external  removal  is  indi- 
cated. After-treatment  of  the  wound  demands  the  use  of  antiseptic 
mouth  washes  and  close  observation.  Timely  interference  is  sometimes 
necessary  to  prevent  occlusion  of  the  duct  and  the  formation  of  a 
salivary  fistula. 

Sialodochitis;  Inflammation  of  the  Excretory  Ducts. — Etiology.— 
In  addition  to  the  inflammatory  results  of  irritation  and  obstruction 
by  foreign  bodies  and  salivary  stones,  an  inflammation  of  the  ducts 
of  salivary  glands  due  to  other  local  irritations  and  infection  some- 
times occurs. 

Such  inflammation  rarely  affects  Wharton's  duct,  but  does  occa- 
sionaly  create  serious  disturbance  in  connection  with  the  duct  of  the 
parotid  gland.  The  most  common  cause  undoubtedly  is  the  presence 
of  worn  sharp  or  jagged  borders  of  tooth  crowns,  and  the  jaw-biting 
habit  referred  to  elsewhere  (p.  280).  How  easily  such  a  simple  etio- 
logical factor  may  be  overlooked  and  how  serious  its  consequences  may 
be  illustrated  by  a  description  of  one  of  the  author's  cases. 

Symptoms. — A  woman  of  middle  age,  unmarried,  gave  a  history  of 
having  had  serious  swelling  in  the  region  of  the  left  parotid,  which  had 
appeared  and  disappeared  for  a  number  of  years.  Her  family  history 
gave  no  indications  of  hereditary  taint.  Her  personal  history  gave 
nothing  which  might  be  accounted  as  an  etiological  factor  except 
marked  neurotic  tendency. 

Symptoms  of  the  attacks  are  those  of  acute  parotitis,  the  gland 


DISEASES  OF  THE  SALIVARY  GLANDS  413 

became  enormously  swollen;  she  suffered  greatly  from  pain,  inability  to 
move  her  Io^^■er  jaw,  and  therefore  to  take  nourishment  comfortably, 
and  the  dread  of  impending  developments  of  yet  graver  conditions. 
The  attacks  lasted  for  two  or  more  weeks,  and  during  this  time  she 
became  ver}'  exliausted;  later  they  gradually  subsided. 

Diagnosis. — Many  physicians  and  surgeons  whom  she  consulted 
during  these  years  had  been  unable  to  recognize  a  definite  cause  for 
her  trouble.  Mumps,  s\Tphilis,  actinomycosis,  neoplasms,  tramnatic 
injuries,  and  general  diseases  of  the  glandular  system  were  readily 
excluded  by  the  symptoms  and  history  of  the  case.  From  constant 
brooding  over  her  troubles  in  anticipation  of  other  attacks,  her  nervous 
state,  as  evidenced  by  trigeminal  pain,  a  morbid  view  of  her  condition 
and  other  subjects,  had  become  noticeable  in  marked  degree. 

Upon  exaviination  of  her  mouth  it  was  found  that  abrasion  of  the 
occlusal  surfaces  of  her  molars  and  second  bicuspids  had  brought 
them  in  conta6t  in  such  a  manner  as  to  favor  cheek  biting  at  a  point 
close  to  the  opening  of  Steno's  duct.  It  was  easily  demonstrated 
that  during  periods  of  pain  or  unusual  nervousness  she  had  been  in 
the  habit  of  grinding  her  teeth.  The  injury  of  the  tissues  of  the  cheek 
had  caused  infection,  followed  by  inflammation  and  occlusion  of  the 
duct.    The  other  sjinptoms  were  thus  easily  and  simply  accounted  for. 

Treatment. — One  of  her  surgeons.  Dr.  C.  A.  Wheaton,  of  St.  Paul, 
by  whom  she  was  referred  to  the  author,  had  wisely  refused  to  perform 
the  operation  for  removal  of  the  gland  in  the  absence  of  positive 
indications  of  its  necessity.  A  cure  was  promptly  effected  by  rounding 
the  buccal  cusps  and  buccoocclusal  borders  of  these  teeth;  afterward 
she  was  referred  to  a  dentist.  The  pulps  of  teeth  which  were  suspected 
of  having  caused  pain  were  removed;  in  two,  pulp  stones  were  found. 
Thus  the  trigeminal  neuralgia,  which  was  undoubtedly  an  exciting 
factor,  was  accounted  for  and  also  relieved. 

Acute  Primary  Inflammations  of  the  Salivary  Glands  (Sialoadenitis 
Acuta). — Etiology. — Acute  primary  non-specific  inflammations  of  the 
salivary  glands  may  result  from  traumatic  injury,  direct  infection, 
and  similar  causes.  It  is  generally  agreed  that  in  most  cases  bacteria 
gain  entrance  from  the  mouth  and  the  oral  cavity. 

Symptoms. — The  symptoms  are  swelling  and  pain,  which  with  other 
signs  of  inflammation  may  vary  in  degree  according  to  the  nature  of 
the  cause. 

Treatment. — The  treatment  consists  of  disinfection  of  the  local 
wound,  if  any,  and  of  the  buccal  cavity,  hot  fomentations  and  soothing 
applications  for  relief  of  the  inflammations,  evacuation  of  pus  if  sup- 
puration occurs,  and  general  treatment  appropriate  to  all  inflammatory 
conditions. 

Miunps. — Etiology. — The  exact  character  of  the  infection  which 
causes  mumps  is  not  yet  established.     I.  C.  Erb^  claims  to  have 

•  Arch.  Int.  Med.,  September,  1909,  after  Practical  Medicine  Series,  Pediatrics,  1900, 
vii,  68. 


414  DISEASES  OF  THE  GLANDS 

isolated  a  microorganism  which  occurred  most  frequently  in  the  form 
of  diplococcus  and  occasionally  in  small  chains.  It  was  non-pyogenic 
and  when  injected  in  Steno's  duct  in  monkeys  and  dogs  caused  a  non- 
suppurative parotitis;  occasionally  it  caused  orchitis.  This  he  believes 
to  be  the  actual  cause,  but  verification  is  required. 

Symptoms. — The  incubation  period  of  approximately  fourteen  days 
is  followed  by  stomatitis  during  a  short  prodromal  stage.  The  first 
symptom  usually  noticed  is  swelHng  in  the  region  of  one  or  both 
parotid  glands.  This  is  most  frequently  unilateral  and  upon  the  left 
side.  As  the  swelling  increases,  the  skin  surface  becomes  tightly 
drawn,  hot,  and  sensitive  to  the  touch.  The  edema  may  be  compara- 
tively slight  and  limited  in  extent,  or  may  spread  as  far  as  the  clavicle. 
The  sublingual  and  submaxillary  glands  may  be  involved  with  corre- 
sponding alteration  of  the  symptoms. 

Feier. — The  rise  in  temperature  is  usually  slight,  but  may  become 
serious  as  a  result  of  complications  which  sometimes  arise  during  the 
progress  of  the  disease.  In  the  absence  of  such  complicating  conditions 
the  fever  disappears  at  the  end  of  about  seven  days,  and  this  is  followed 
by  subsidence  of  all  symptoms  in  the  course  of  two  or  three  weeks. 

Pain. — Pain  may  be  a  notable  feature  and  radiating  and  severe  in 
character,  or  may  cause  slight  discomfort  according  to  the  extent  of 
the  swelling  and  the  tendency  of  the  glands  to  break  down  and  form 
abscesses. 

Metastasis. — In  adults  there  is  often  marked  tendency  to  metas- 
tatic involvement  of  other  glands,  particularly  the  testes,  ovaries,  and 
other  generative  organs.  Swellings  of  these  organs  occur  with  pain, 
tenderness,  and  occasional  abscess  formation. 

Complications. — Orchitis. — Through  metastasis  there  may  be  a  very 
tender  swelling  of  one  or  both  testes,  which  may  subside  gradually 
under  treatment  or  result  in  suppuration.  The  epididymis  and  seminal 
cord  are  generally  unaffected.  In  treatment  the  parts  are  elevated 
and  local  applications  employed  to  relieve  the  inflammation  and  pain. 

Other  complications  are  cystitis,  nephritis,  and  afPections  of  the 
eye  and  ear. 

Prognosis. — In  young  children  mumps  usually  runs  its  course  ^^•ith 
comparatively  little  tendency  to  complications.  In  older  persons, 
especially  when  orchitis  has  occurred,  the  prognosis  is  much  more 
grave.  Atrophy  of  the  testicles  follows  orchitis,  according  to  Kocher, 
in  about  one-third  of  the  cases.  This  may  be  complete  or  partial,  and 
may  affect  both  testes  with  resulting  impotency. 

Treatment. — The  treatment  should  be  in  the  nature  of  careful  and 
regularly  continued  disinfection  of  the  mouth  by  keeping  the  teeth 
clean,  and  the  use  of  suitable  antiseptic  mouth  washes.  Local  appli- 
cations of  heat  or  cold  are  indicated,  if  necessary  to  relieve  distress. 
Patients  should  be  kept  warm  and  quiet  (preferably  in  bed)  and  given 
nourishing,  easily  digested  liquid  diet;  the  bowels  and  kidneys  should 
be  carefully  regulated. 


DISEASES  OF  THE  SALIVARY  GLANDS  415 

The  formation  of  abscesses  may  require  treatment,  or  it  may  be 
necessary  to  relieve  pain  by  the  use  of  hot  applications  and  opiates,  to 
open  and  f2;ive  direct  relief  as  with  other  suppurative  conditions. 

Infantile  Sialoadenitis. — ^This  is  a  form  of  acute  primary  inflam- 
viation  of  the  suhlimjual  and  suhmaxiUary  glands  toithout  inwliement 
of  the  parotid,  which  sometimes  affects  nursing  infants  during  the  first 
weeks  of  life. 

Etiology.— The  etiology  is  not  known,  but,  as  suggested  by  Henning, 
the  disease  is  presumably  due  to  some  puerperal  condition  of  the 
mother. 

Symptoms.— The  glands  swell  rapidly  and  pus  is  discharged  through 
the  excretory  ducts. 

Prognosis. — The  prognosis  is  favorable,  if  the  general  health  of  the 
infant  is  sufficient  to  withstand  the  effect  of  the  sore  mouth  and 
infection. 

Treatment.— The  mouth  should  be  kept  clean.  If  suppuration  is 
extensive,  an  incision  is  made  and  drainage  given  as  in  surgical  treat- 
ment for  the  relief  of  other  forms  of  abscesses. 

Acute  Secondary  Inflammation  of  the  Salivary  Glands.— Etiology.— 
The  causes  of  secondary  sialoadenitis  are  both  local  and  general. 

Local  Causes. — Local  causes  are  the  secondary  results  of  inflamma- 
tion attendant  upon  foreign  bodies,  stones,  tramnatic  injuries,  and 
similar  factors,  or  infection  from  IjTnph  nodes,  mercurial  or  other 
forms  of  stomatitis,  diseased  roots  of  teeth,  and  the  inflammatory 
conditions  incident  to  malerupting  third  molars. 

General  Causes.— Such,  inflammations  arise  secondarily  as  com- 
plications of  infectious  diseases,  such  as  scarlet  fever,  pneumonia, 
smallpox,  measles,  typhus  fever,  pyemia,  septicemia,  and  similar 
affections;  they  also  occur  from  carcinoma  and  subsequent  to  surgical 
operations  through  infection  and  general  reduction  of  constitutional 
resistance,  as  from  severe  abdominal  operations. 

Symptoms.— The  swelling  usually  appears  in  the  parotid  region  and 
closely  resembles  that  of  mumps;  in  cases  of  virulent  infection,  however, 
it  progresses  much  more  rapidly  and  to  greater  extent,  with  correspond- 
ing alteration  in  the  appearance  of  the  skin,  which  becomes  discolored 
and  the  vascular  structures  extensively  dilated.  The  fever  is  high 
and  there  is  much  more  likelihood  of  abscess  formation  and  tissue 
destruction.  Jaw  movement  is  limited  or  completely  checked.  Hear- 
ing is  more  or  less  afl'ected.  In  rare  instances  the  facial  nerve  may  be 
involved,  but  this  is  unusual. 

If  the  swelling  does  not  recede  to  a  noticeable  degree  after  four  or 
five  days,  suppuration  is  indicated  even  though  the  presence  of  pus 
may  not  be  revealed  by  palpation  on  account  of  the  tensity  of  tissues 
surrounding  the  parotid  gland. 

Diagnosis.— Mumps  usually  can  be  excluded  by  history  of  a  previous 
attack,  and  in  the  absence  of  clear  testimony  upon  this  point  the  fact 
that  the  inflammation  of  the  glands  is  secondary  makes  it  possible  in 


416  DISEASES  OF  THE  GLANDS 

most  cases  to  recognize  the  disease  that  preceded  it.  Occasionally  the 
cause  is  hidden  and  differentiation  from  phlegmon  of  the  neck  and 
diseases  of  the  jaw  and  l}'mph  nodes  is  difficult. 

Prognosis. — The  prognosis  is  much  more  serious  than  in  the  case  of 
primary  sialoadenitis,  but  it  necessarily  varies  with  the  nature  of  the 
cause. 

Treatment. — Oral  Prophylaxis. — Oral  prophylaxis  is  a  first  essential. 
If  the  jaws  can  be  opened  sufficiently  the  necks  and  crowns  of  all 
teeth  should  be  cleaned  and  disinfected.  ^Slouth  washes  should  be 
used,  preferably  dioxogen,  alternately  once  each  hour  with  some  one 
of  the  agreeable  reliable  antiseptic  mouth  washes.  \Yhen  the  jaws  are 
more  or  less  fixed,  cotton  wrapped  upon  a  toothpick  or  probe  may  be 
passed  under  the  lips  and  cheek,  or  between  the  anterior  teeth,  and  if 
possible  over  and  around  the  tongue. 

Twice  daily  tincture  of  iodin,  10  per  cent,  solution,  should  be  used 
in  this  way,  and  dioxogen  frequently. 

Efforts  to  Abort  the  Inflammation. — Hot  fomentation  or  cold  appli- 
cations to  the  surface,  bathing,  and  gentle  massage  with  30  per  cent, 
alcohol,  hot-water  bags  and  other  means  of  preventing  the  progress 
of  the  inflammation  should  be  employed.  Pain  may  require  hypo- 
dermic injections  of  morphin,  or  iodin  for  its  relief. 

Surgical  Treatment. — When  an  abscess  is  formed  it  must  be  opened 
and  drained.  The  external  incision  is  made  in  such  a  manner  as  to 
avoid  important  nerve  structures,  and  blunt  dissection  is  used  to  open 
the  gland  until  the  pus  is  reached.  The  removal  of  the  necrotic  tissue 
and  suitable  drainage  is  required,  as  in  the  treatment  of  other  abscesses. 

The  original  source  of  infection  must  recei\"e  treatment  to  prevent 
recurrence  of  the  trouble. 

General  Treatment. — Aid  should  be  gWeii  to  the  eliminative  organs 
to  keep  up  their  acti^^ty,  and  supportive  measures  should  be  directed 
toward  building  up  resistance  by  increase  of  bodily  strength. 

Chronic  Inflammations  of  the  Salivary  Glands. — Etiology. — Long- 
continued  and  slowly  progressi\"e  swelling  sometimes  affect  these 
glands,  particularly  the  submaxillary.  No  definite  cause  appears. 
The  author's  experience,  however,  leads  him  to  believe  that  it  is  some- 
times a  result  of  infection  from  some  chronic  mouth  affection. 

Syphilis,  tuberculosis,  and  tumors  are  commonly  excluded  as  factors 
in  these  cases. 

Symptoms. — The  gland  is  more  or  less  enlarged,  slightly  indurated, 
the  overlying  tissue  is  very  slightly  or  not  at  all  adherent,  and  the  tumor 
more  or  less  movable. 

Treatment. — The  treatment  comprises  correction  of  the  cause,  relief 
of  the  inflammatory  s^Tuptoms,  and  ^emo^'al  of  the  gland  if  absolutely 
required,  but  not  otherwise. 

Chronic  Secondary  Inflammations.^ — Etiology. — Chronic  enlarge- 
ments of  the  salivary  glands  commonly  result  from  the  intoxications 
of  mineral  and  other  poisons,  such  as  mercury,  lead,  copper,  iodin. 


DISEASES  OF  THE  SALIVARY  GLANDS  417 

opium,  etc.  In  uremia  and  similar  affections  such  glandular  conditions 
also  occur. 

Symptoms. — ^The  disease  shoAVs  itself  in  chronic  enlargements,  with 
more  or  less  induration  of  the  glands. 

Treatment. — Removal  of  the  cause  is  usuall}^  sufficient.  When 
chronic  changes  have  progressed  too  far  the  glands  may  become  a 
menace  and  require  removal. 

Ptyalism;  Sialorrhea  or  Hypersecretion. — Etiology. — Inflammations 
of  the  mouth  are  the  most  common  causes.  It  is  a  prominent  s}Tnptom 
of  mercurial,  phosphorus,  and  copper  poisoning;  it  may  also  be  caused 
by  certain  drugs,  such  as  the  iodin  preparations,  jaborandi,  etc.  It 
is  a  symptom  of  certain  diseases  AA'hich  involve  the  nervous  system, 
either  primarily  or  secondarily,  such  as  hydrophobia,  hysteria,  trifacial 
and  other  forms  of  neuritis,  and  is  a  distressing  feature  of  facial 
paralysis. 

Symptoms. -^The  one  dominant  symptom  is  an  excessive  flow  of 
saliva. 

Treatment.- — The  cause  should  be  corrected  whenever  possible. 
Astringent  drugs  are  more  or  less  recommended,  but  in  the  author's 
experience  have  usually  failed  to  give  permanent  relief  when  the 
causative  factor  was  beyond  control. 

Aptyalism;  Xerostoma,  Dry  Mouth. — Etiology .^ — Its  exact  cause  is 
not  understood,  but  it  is  believed  to  be  due  to  diabetes. 

Symptoms.^ — Insufficient  saliva  secretion  causes  excessive  dryness  of 
the  mouth. 

Treatment. — The  treatment  must  necessarily  be  empirical  until  its 
causes  are  better  understood.  The  distressing  dryness  may  be  relieved 
by  soothing  local  applications  and  correction  of  general  conditions  of 
health. 

Bilateral  Parotid  Tumors. — Bilateral  enlargement  is  more  or  less 
rare,  although  unilateral  parotid  tumor  is  not  uncommon.  The  latter 
are  commonl}'  mixed  tumors,  tubercular  glands,  parotid  cysts,  or  the 
results  of  infection  parotid.  Gordon  B.  New,  of  the  IMayo  Clinic,  gives 
the  following  classification  of  bilateral  parotid  tumors: 

1.  Recurrent  bilateral  parotid  tumors. 

2.  Syphilitic  bilateral  parotid  tumors. 

3.  Tuberculous  bilateral  parotid  tumors. 

4.  Bilateral  parotid  tumors  associated  with  leukemia. 

5.  Mikulicz's  disease. 

6.  Bilateral  parotid  tumors  due  probably  to  a  local  infection. 

A  number  of  cases  have  been  reported  in  AAhich  bilateral  swelling 
of  the  parotid  glands  of  intermittent  character  was  apparentl}^  due 
to  certain  kinds  of  food.  The  swelling  may  last  an  hour  or  two  and 
quickly  subside.  Friedberg's  suggestion  that  spasmodic  closure  of  the 
ducts  is  brought  on  by  the  stimulation  of  foods,  appears  to  be  the  most 
satisfactory  way  of  accounting  for  this  affection.  The  diagnosis  of  the 
syphilitic  and  tubercular  types,  as  well  as  those  due  to  local  infection 
27 


418 


DISEASES  OF  THE  GLANDS 


and  the  treatment  thereof  must  be  largely  determined  in  the  same 
manner  as  for  other  forms  of  these  affections.  Their  association  with 
lymphatic  leukemia  and  Mikulicz's  disease,  however,  points  to  a  wide 
field  of  investigation  as  yet  too  unsettled  to  warrant  definite  etiological 
conclusions. 

Mikulicz's  Disease. — Etiology. — Nothing  is  known  of  the  cause  and 
nature  of  this  affection. 

Symptoms. — The  symptoms  are  a  uniform  swelling  occurring  usually 
in  middle  life  and  progressing  slowly,  the  distinctive  feature  of  which 
is  the  syinmetrical  enlargement  of  the  glands  of  the  head,  particularly 
the  salivary  glands.     Both  parotids,  the  submaxillary,  sublingual,  and 


Fig.  244. — Symmetrical  affection  of  the  lacrimal  and  salivary  glands:  a,  the  enlarged 
sublingual  glands.     (After  Mikulicz.) 


lacrimal  glands  are  involved,  as  may  also  be  the  palatine  and  labial 
glands.  The  parotids  may  become  as  large  as  a  moderate-sized  apple, 
with  proportionate  enlargement  of  the  other  glands.  All  of  these  glands 
may  not  be  affected,  but  there  must  be  a  sufficient  number  of  them 
to  give  the  symmetrical  effect  in  order  that  the  case  may  be  correctly 
diagnosticated  as  Mikulicz's  disease.  As  might  be  expected,  the 
adjoining  lymphatics  are  also  frequently  involved  (Fig.  244). 

The  disease  does  not  spread  beyond  the  gland  capsule,  and  the 
tumor  is  therefore  movable  under  the  skin.  Its  consistency  may  vary, 
but  there  is  no  fluctuation  and  there  are  no  inflammatory  symptoms, 
such  as  pain  or  unusual  tenderness.  Osier  describes  one  case  in  which 
there  was  enlargement  of  the  spleen,  and  states  that  blood  examination 
is  negative.    Movement  of  the  jaw  is  interfered  with,  but  it  is  not  pain- 


DISEASES  OF  THE  SALIVARY  GLANDS 


419 


Fig.  2-45. — Bilateral  parotid  tumor  asso- 
ciated -n-ith  lymphatic  leukemia.  (After 
New.) 


Fig.  246.- 


-Mikulicz'a    disease. 
New.) 


(After 


Fig.  247. — Mikulicz"'s  disease. 
New.) 


(After 


Fig.  248. 


-Mikulicz's  disease. 
New.) 


(After 


420  DISEASES  OF  THE  GLANDS 

fill.  The  mucous  membrane  of  the  mouth  suffers  unusual  dryness 
through  imperfect  function  of  the  diseased  glands.  Interstitial  gin- 
givitis with  marked  loosening  of  the  teeth  has  been  described  in  some 
cases,  but  whether  infection  from  this  cause  is  an  etiological  factor  or 
the  condition  of  the  teeth  a  result  of  the  disease  is  not  fully  understood. 

Diagnosis.- — Diagnosis  depends  upon  the  symmetrical  and  uniform 
enlargement  of  the  affected  glands,  the  absence  of  inflammatory 
symptoms,  and  exclusion  of  malignant  growths. 

Prognosis.— The  disease  is  not  directly  dangerous  to  life.  Its  course 
is  variable,  sometimes  remaining  stationary  and  occasionally  receding 
after  intercurrent  febrile  diseases  or  as  a  result  of  treatment.  With 
regard  to  cure,  the  prognosis  is  doubtful. 

Treatment. — Arsenic  and  potassium  iodide  are  much  recommended, 
and  when  these  or  similar  remedies  fail,  surgical  removal  of  the  gland 
may  be  performed.  This,  however,  should  be  avoided  except  in  cases 
where  such  procedure  is  warranted  by  marked  disfigurement. 

The  following  diseases  may  primarily  or  secondarily  affect  the 
salivary  glands  as  they  do  other  structures  of  the  body.  Further 
description  is  given  in  detail  under  their  respective  headings  as  indi- 
cated. 

Actinomycosis. — (See  page  162.) 

Tuberculosis. — (See  page  94.) 

Syphilis.— (See  page  107.) 

Ranula. — (See  page  436.) 

Cysts. — Cysts  of  the  Salivary  Ducts. — (See  page  435.) 

Cysts  of  the  Salivary  Glands. — (See  page  435.) 

Tumors  of  the  Salivary  Glands. — (See  page  417.) 

Adult  Epithelial  Tumors. — Adenomata  (page  452)  occasionally  occur 
but  are  very  rare. 

Embryonic  Epithelial  Tumors.— (See  page  444.) 

Eintheliomata  (page  474)  are  the  most  frequent. 

Encephaloid  (page  476)  are  rare. 

Adult  Comiective-tissue  Tumors. — Chondromata. — (See  page  458.) 

Fibromata. — (See  page  460.) 

Myomata  (page  461)  are  found  occasionally. 

Angiovia  (page  462)  are  rare,  and  the  diagnosis  is  often  questionable. 

Lymyh angioma. — (See  page  464.) 

Lipoma. — (See  page  457.) 

Myxoma. — (See  page  467.)  The  existence  of  pure  myxoma  of  these 
glands  is  questionable,  for  most  of  them  are  mixed  tumors. 

Embryonic  Connective-tissue  Tumors  (page  468)  are  rare. 

Mixed  Tumor  (page  468)  is  the  most  frequent  parotid  neoplasm, 
and  most  of  these  are  endotheliomata. 

Sjrmptoms  and  Treatment.- — Sjonptoms  and  treatment  of  these 
growths  do  not  differ  materially  in  salivary  glands  from  other  situa- 
tions of  the  body,  and  are  therefore  described  under  their  several 
subjects  as  indicated. 


DISEASES  OF  LYMPH  NODES  OF  THE  MOUTH  421 

DISEASES  OF  THE  LYMPH  GLANDS  OR  LYMPH[N0DES  OF  THE 
MOUTH  AND  ASSOCIATED  PARTS. 

Adenoids;  Adenoid  Vegetations,  Pharyngeal  Adenoids,  -Pharyn- 
geal Tonsils,  Epipharyngeal  Tonsils,  Postnasal  Adenoids,  Hyper- 
trophy.— Definition. — Adenoids  are  hypertrophied  lymph  glands  which 
normally  exist  in  the  epipharyngeal  space.  They  are  usually  found 
on  the  superior  and  posterior  walls  of  the  epipharynx. 

Etiology. — Practically  all  the  factors  leading  to  chronic  irritation 
and  inflammation  in  the  nasal  and  pharyngeal  regions  may  be  grouped 
as  causes  of  adenoids. 

Ballenger  believes  their  chief  cause  to  be  irritation  of  the  epipharynx 
during  attacks  of  exanthematous  fever,  and  calls  attention  to  the  fact 
that  lymphatic  structures  of  children  become  enlarged  or  h\-pertro- 
phied  in  response  to  bacterial  stimulation  more  markedly  than  the  same 
structures  in  adults  under  similar  conditions.  He  holds  that  as  the 
exanthematous  fevers  occur  chiefly  in  early  childhood  there  is  a  special 
susceptibility  to  adenoids  during  this  period  of  life.  It  must,  however, 
be  remembered  in  this  connection  that  adenoids,  which  may  occur  at 
any  period  of  life  but  are  usually  found  between  the  ages  of  five  and 
sixteen  years,  afl:'ect  large  numbers  of  children  whose  histories  contain 
no  record  of  previous  attacks  of  any  of  the  exanthemata.  ^Moreover, 
the  common  association  of  adenoid  vegetations  with  other  develop- 
mental abnormalities  or  defects  and  their  frequent  existence  in  members 
of  the  same  family  which,  while  the  use  of  the  term  hereditary  may  be 
unwarranted,  showe  at  least  a  predisposition  that  is  undoubtedly 
inherited.  In  some  cases  at  least  there  is  an  underlying  developmental 
tendency,  and  upon  this  foundation  any  factor  leading  to  chronic 
diseases  of  nasopharyngeal  structures  may  act  as  direct  causes. 

Hypertrophy  of  the  Tonsils. — In  rare  cases  this  affection  is  congenital, 
infants  having  been  born  with  enlarged  tonsils.  Usually,  however, 
it  begins  about  the  second  year  of  life,  and  continues  until  young 
adulthood,  after  which  there  is  gradual  tendency  to  reduction  in  size. 

While  many  predisposing  factors  are  recognized  and  the  close  rela- 
tion of  this  process  to  other  glandular  influences  upon  development 
is  beginning  to  be  understood,  the  essential  underlying  cause  has  not 
yet  been  definitely  proved.  ]Many  disease  processes  may  lead  to  ton- 
sillar enlargement,  as  in  acute  lingual  tonsillitis.  The  association  of 
unhealthful  nasal,  buccal,  and  pharyngeal  tissues  occurs  so  frequently 
that  their  pathological  relation  appears  to  be  beyond  question. 

Symptoms  of  Adenoids  and  Enlarged  Tonsils. — Adenoids  and  enlarged 
tonsils  are  found  together  in  the  same  individuals  in  a  large  majority 
of  cases.  The  important  features  when  contemplated  in  their  relation 
to  pathological  conditions  of  the  mouth,  pertain  chiefly  to  the  gen- 
eral involvement  of  pathological  and  developmental  conditions.  This 
includes  diseases  of  the  mouth,  nose,  pharynx,  throat,  the  sinuses  of 
the  head,  the  form  of  the  dental  arches,  palate,  and  face,  and  their 


422 


DISEASES  OF  THE  GLANDS 


Fig.  249. — Drawing  of  the  palate  of  a  young  woman,  aged  twenty  years,  whose  faucial 
pillars  were  injured  in  the  course  of  a  tonsil  operation,  shows  shortening  and  deflection 
of  the  palate,  fluids  escaped  through  the  nose  in  swallowing  and  speech  very  imperfect. 


Fig.  250  — Same  case  after  operation. 


DISEASES  OF  LYMPH  NODES  OF  THE  MOUTH 


423 


direct  or  indirect  effect  upon  more  remote  parts  or  the  organism  as  a 
whole.  Any  of  these  affections  may  be  primary  or  secondary  causes 
of  both  adenoids  and  h>-pertrophy  of  the  tonsils  as  well  as  other  dis- 
eases of  the  nose  and  throat,  or  the  pathological  influence  may  be 
exerted  in  a  reverse  direction.    Knowledge  of  the  s\-mptomatology  of 


Fig.  251.— Atresia  of  the  palatopharj-ngeal  opening  resulting  from  imperfect  tonsil 
and  adenoid  removal.  Case  of  a  boy,  aged  nine  years.  The  soft  palate  was  adherent 
to  the  posterior  vraM  of  the  pharj-nx  on  the  right  side,  a  very  sUght  opening  being  left 
upon  the  left  side.  A  number  of  attempts  to  correct  the  trouble  resulted  in  faHure. 
Among  these  the  ill-ad^-ised,  though  sometimes  recommended  attempt  to  transplant 
mucous  membrane  to  cover  the  raw  posterior  surface  of  the  palate.  Such  efforts  in  these 
eases  are  useless.  Mucous  membrane  does  not  transplant  well,  the  tissues  are  always 
distorted  when  the  incisions  are  made  so  that  perfect  coaptation  is  impossible,  and 
there  is  alwavs  infection  to  attack  the  transplanted  tissue.  Diiring  several  years  of 
enforced  mouth-breathing,  nasal  disease  had  become  marked,  the  nares  narrow  and  the 
septum  deflected.  As  a  first  step  the  maxillse  were  separated,  the  nares  thus  enlarged, 
the  deflected  septimi  relieved  and  more  healthful  nasal  conditions  secured.  Follow-ing 
this  an  operation  was  performed  as  shown  in  the  illustration,  with  complete  relief. 

these  affections  is  therefore  necessary  for  the  oral  surgeon.  It  is  fre- 
quently a  method  of  much  importance  properly  to  decide  whether 
the  treatment  of  adenoids  and  tonsils  should  precede  correction  of  the 
mouth  affection  or  this  order  be  reversed. 

Treatment.— It  is  the  author's  belief  that  the  treatment  of  intra- 
nasal and  phar^-ngeal  diseases  should  be  referred  to  those  who  specialize 


424 


DISEASES  OF  THE  GLANDS 


in  nose  and  throat,  and  that  the  indiscriminate  attempts  at  removal 
of  adenoids  and  enlarged  tonsils  by  those  whose  special  training  does 
not  fit  them  for  the  attainment  of  the  best  results  in  this  direction  is 
pernicious  in  its  tendency. 

For  this  reason  no  attempt  will  be  made  to  describe  these  opera- 
tions in  detail  in  this  work. 

Serious  and  absolutely  unnecessary  hemorrhage,  imperfect  opera- 
tions that  caused  continuance  rather  than  relief  of  disease,  and  injuries 
to  nerves  or  the  tissues  of  the  faucial  pillars  and  the  soft  palate  that 
have  led  such  patients  to  apply  to  the  author  for  operation  for  relief 


/-^fr^ 

7^ 

'%^ 

J:} ' 

y  ^ 

{\\ 

1 

ti 

^ 

Fig.  252. — The  same  case  as  in  Fig.  251,  in  course  of  correction  after  the  ligature  is 
tied.    The  usefulness  of  the  parts  in  swallowing  and  speech  was  completely  restored. 

of  speech  defects,  the  same  as  cleft-palate  cases,  are  results  that  have 
frequently  come  under  his  observation  when  unskilled  operations  have 
been  undertaken  to  remove  adenoids  and  tonsils 

Examples  of  such  postoperative  defects  are  shown  in  Figs.  249-253. 
Fig.  249,  which  is  a  drawing  illustrating  the  case  of  a  young  woman, 
aged  twenty  years,  whose  faucial  pillars  upon  one  side  were  injured  in 
the  course  of  an  ill-advised  tonsillectomy.  She  suffered  great  distress 
through  imperfect  speech,  fluids  came  through  her  nose  in  deglutition, 
and  her  nervous  condition  became  serious  in  many  respects.  Fig.  250 
shows  the  author's  operation  for  correction  of  defects  of  this  character 
through  which  the  patient  was  enabled  to  drink  water,  and  speak  with- 
out difficulty  after  operative  treatment. 


DISEASES  OF  LYMPH  NODES  OF  THE  MOUTH 


425 


Fig.  251  presents  another  form  of  ill-result  from  careless  or  unskilful 
adenoid  and  tonsil  removal  in  which  there  is  adhesion  of  the  soft  palate 
to  the  posterior  wall  of  the  pharynx.  This  boy,  nine  years  old,  had  the 
soft  palate  on  one  side  adherent  to  the  posterior  pharyngeal  wall,  as  a 
result  of  adenoid  and  tonsil  operations  four  years  previously.  During 
this  time  an  attempt  had  been  made  to  free  the  palate,  and  transplant 
mucous  membrane  to  prevent  the  tissues  from  uniting.  At  this  opera- 
tion he  was  under  an  anesthetic  nearly  all  of  one  day  and  almost  died, 
but  the  original  condition  remained.  Attempts  to  stretch  the  parts 
had  onlv  made  him  more  in  terror  of  doctors  and  doctors'  offices,  and 


Fig.  253. — Illustration  of  the  contracted  nasopharyngeal  opening  of  a  child,  aged  six 
years,  resulting  from  a  tonsil  operation.  The  soft  palate  on  both  sides  in  this  case  is 
adherent  to  the  pharyngeal  wall.    The  small  opening  just  under  the  uvula  is  shown. 


did  no  good  whatever.  Nasal  disease,  quite  marked  deafness,  defective 
speech,  and  both  palatal  and  nasal  defects  all  combined  to  make  his 
condition  very  serious.  As  a  first  step,  his  maxillae  were  separated  to 
enlarge  the  nares  and  facilitate  more  healthful  pharyngeal  conditions. 
This  gave  marked  improvement  in  respiration,  better  general  health, 
and  a  more  healthful  condition  of  the  local  tissues  and  secretions,  after 
which  the  operation  illustrated  in  Fig.  252  was  performed  with  com- 
plete success. 

In  these  cases  cutting  the  palate  free  from  the  pharyngeal  wall  only 
results  in  their  reuniting  again  with  additional  scar  contraction. 


426  DISEASES  OF  THE  GLANDS 

The  loop  suture  causes  pressure,  absorption,  and  the  tendency  is 
toward  progressive  increase  of  the  nasopharyngeal  opening,  instead 
of  its  becoming  smaller  as  would  otherwise  occur.  Fig.  253  indicates 
the  condition  of  almost  complete  stenosis  of  the  nasal  pharyngeal 
passage  of  a  child,  aged  six  years.  This  little  fellow  is  a  twin,  ever  so 
much  smaller,  bent-shouldered,  more  markedly  nervous,  and  generally 
ill  developed  than  his  brother.  The  difference  is  undoubtedly  due  to 
the  atresia  of  the  palate  and  its  consequences,  all  of  which  were  caused 
by  the  removal  of  adenoids  and  tonsils  in  an  unskilful  manner.  Fig. 
253  shows  the  operation  which  was  performed  by  which  benefit  was 
given  to  enable  him  to  improve  in  both  health  and  speech. 

Suprahyoid  Median  Phlegmon.— Etiology.— This  affection  is  ob- 
viously due  to  some  form  of  infection  and  is  undoubtedly  closely 
allied  to  Ludwig's  angina. 

Symptoms. — In  typical  cases  the  patient  keeps  the  mouth  open, 
salivation  and  deglutition  are  impossible,  respiration  is  interfered  with. 
A  swelling  will  be  found  in  the  suprahyoid  region  in  the  mouth,  an 
elevation  of  the  floor  which  lifts  up  the  edematous  tongue.  In  some 
cases  the  condition  can  only  be  discovered  by  bimanual  palpation,  one 
finger  in  the  mouth,  the  other  under  the  chin. 

Treatment. — Prompt  treatment  is  required.  An  incision  should  be 
made  from  the  tip  of  the  chin  nearly  to  the  hyoid.  Incision  in  the 
mouth  is  advisable  only  when  the  collection  protrudes  more  into  that 
cavity.  There  is  no  occasion  to  wait  for  formation  of  pus,  the  appear- 
ance of  the  swelling  together  with  its  rapid  extension  both  attest  the 
gravity  of  the  condition.  Lejars^  cites  a  case  showing  the  dangers  of 
delay:  "A  man,  aged  sixty-five  years,  apparently  in  vigorous  health, 
had  a  swelling  such  as  had  been  described ;  as  the  fever  was  slight  and 
the  general  condition  good,  some  days  passed  with  nothing  done  but 
lavage,  etc.,  then  a  short  intrabuccal  incision  evacuated  a  little  blood. 
However,  there  was  some  relief,  and  again  for  some  days  nothing  more 
was  done,  the  swelling  grew  larger  and  the  whole  region  was  thick  and 
swollen.  The  actual  cautery  was  used  and  some  pus  and  turbid  serum 
evacuated.  There  was  improvement  for  forty-eight  hours,  then  the 
swelling  rapidly  extended  laterally;  this  time  heroic  measures  were 
undertaken,  the  region  was  freely  opened  and  punctured  with  the 
cautery,  but  it  was  too  late." 

Lymphadenitis;  Lymphangitis. — These  terms  denote  inflammation 
of  the  lymph  node. 

Etiology. — Practically  every  form  of  infection  affects  the  lymph  nodes 
because  of  their  unusual  susceptibility  to  the  influence  of  bacteria  or 
their  toxic  products.  Tuberculosis,  syphilis,  bubonic  plague,  leprosy, 
actinomycosis,  glanders,  diphtheria,  scarlet,  typhoid,  and  other  fevers, 
and  infectious  diseases  give  rise  to  adenitis,  which  may  be  apparent 
in  the  Ijoiiph  channels  of  the  neck  or  other  regions.    Infection  from 

*  Semaine  med.,  November  10,  1909. 


DISEASES  OF  LYMPH  NODES  OF  THE  MOUTH  427 

disease  of  the  mouth  is,  of  course,  an  important  factor  in  this  relation. 
This  is  emphasized  by  CopUn'  as  follows: 

"Cervical  tul)erculous  lymphadenitis  is  clearly  the  result  of  infec- 
tion from  the  oral  and  pharyngeal  cavities.  Halle  found  that  in  31(31 
children  with  enlarged  cervical  glands,  2334  had  carious  teeth;  and  of 
these,  164G  corresponded  in  location  with  the  enlarged  glands.  Cden- 
thal,  among  987  children,  found  decayed  teeth  in  429;  424  of  these  had 
enlarged  lymph  nodes.  Halle  demonstrated  that  if  cavities  in  the 
teeth  of  dogs  be  packed  with  Prussian  blue  and  cemented,  the  pigment 
may,  in  from  two  to  three  days,  be  present  in  the  nearest  lymph  nodes. 
Dieulafoy  and  others  have  shown  that  tonsils — frequently  without 
evidence  of  tuberculosis — may  contain  the  bacillus,  and  that  the 
organism  often  is  present  in  adenoids." 

Symptoms.^ — Inflammation  of  a  lymph  node  may  be  acute  or  chronic. 
In  acute  cases  the  node  becomes  swollen,  tense,  and  tender.  On 
account  of  the  obstruction  to  the  passage  of  fluid  the  swelling  may 
extend  to  other  tissues  of  the  area  drained,  thus  giving  rise  to  a  jxira- 
lymphadenitis.  The  course  may  be  fulminating  and  pass  more  or 
less  rapidly  to  suppuration  until  the  gland  becomes  a  necrotic  mass 
(bubo),  or  chronic  changes  may  take  place  with  induration  that  may 
persist  for  months  or  years  without  noticeable  change. 

Treatment. — The  treatment  must,  of  course,  be  governed  by  the 
nature  of  the  cause.  If  due  to  mouth  infection,  the  buccal  secretions 
must  be  disinfected  and  the  local  disease  properly  treated.  Tuber- 
culosis, syphilis,  and  general  infections  require  measures  appropriate 
to  the  general  treatment  of  such  diseases. 

In  the  absence  of  entirely  evident  sources  of  infection  in  the  mouth, 
such  as  extensive  dental  caries,  discharging  dental  abscesses,  extensive 
diseases  of  the  mucous  membrane,  and  similar  affections,  care  should 
be  taken  to  test  the  responsiveness  of  all  the  teeth  upon  the  afl^ected 
side  to  heat  and  cold  in  order  to  determine  whether  by  any  chance 
there  may  be  a  devitalized  tooth.  Without  giving  outward  evidence 
of  disease  or  noticeable  symptoms  of  pain,  such  teeth  have  been  fre- 
quently kno\\n  to  be  the  source  of  extensive  infection  which  is  the  more 
to  be  feared  because  the  real  cause  is  apt  to  be  overlooked. 

Another  valuable  method  of  examination  for  the  same  purpose  is 
to  test  the  color  of  teeth  by  the  use  of  a  small  electric  mouth  lamp. 
This  usually  reveals  difference  in  translucency  betw'een  devitalized 
teeth  and  those  having  living  pulps.  If  a  tooth  be  found  in  a  devital- 
ized condition,  its  history  must  be  carefully  studied  to  learn  whether 
the  pulp  has  been  previously  extracted  and  the  roots  properly  filled 
or  not. 

Many  times  the  only  satisfactory  method  is  to  have  a  dentist  open 
the  root  canals  and  thoroughly  cleanse  and  fill  them  as  a  matter  of 
precaution. 

'  Manual  of  Pathology,  pp.  445  and  446. 


428  DISEASES  OF  THE  GLANDS 

Interstitial  gingivitis,  especially  in  the  form  of  pyorrhea  alveolaris, 
with  chronic  discharge  of  pus  from  pockets  about  the  necks  of  the  teeth, 
is  a  relatively  frequent  cause,  and  in  many  cases  easily  overlooked  in 
superficial  examination  of  the  mouth.  Discharges  from  beneath  gum 
surfaces  surrounding  the  crowns  and  necks  of  partially  erupted  teeth 
are  also  a  cause  that  might  readily  be  overlooked.  Adenoids  and 
enlarged  tonsils  are  sources  of  infection  constantly  under  the  observa- 
tion of  dentists  as  well  as  other  practitioners. 

When  a  chain  of  lymph  nodes  is  involved,  and  it  is  evident  that  the 
infection  has  extensively  invaded  the  cervical  lymphatics,  the  removal 
of  such  glands  by  complete  dissection  is  called  for  (see  page  487).  The 
modern  tendency,  however,  is  to  treat  these  nodes  individually  if  there 
is  no  evidence  of  extensive  invasion  and  w^hen  operation  can  be  per- 
formed sufficiently  early  to  enucleate  and  remove  the  particular  node 
that  is  affected  without  extirpation  of  the  entire  chain  en  masse.  The 
.T-rays  appear  to  exert  a  valuable  influence  in  the  treatment  of  these  cases. 

"Hodgkin's  Disease,  Lymphadema,  Lymphadenoma,  Lympho- 
sarcoma, Progressive  Lymphadenoid  Hyperplasia,  Malignant 
Lymphoma,  Simple  Adenia,  Pseudoleukemia,  Malignant  Lymph- 
adenoma. — These  and  other  more  or  less  synonymous  terms  have 
been  applied  to  a  peculiar  form  of  lymphoid  change  in  which  one  or 
more  of  the  lymphadenoid  tissues  of  the  body  are  involved,  including 
not  only  the  lymph  nodes,  the  spleen,  and  the  tonsils,  but  even  the 
lymphoid  tissues  of  the  various  mucosa.  Without  doubt  a  number  of 
conditions  have  been  included  in  this  group.  Careful  study  by  modern 
methods,  particularly  the  investigations  by  Reed,  Simmons,  and  Long- 
cope,  render  it  possible  to  recognize  a  fairly  definite  anatomical  picture, 
which  is  distinct  from  neoplasms  affecting  the  lymph  nodes  and  not 
due  to  any  form  of  infection  with  which  we  are  at  present  familiar."^ 

Etiology.— Dr.  John  L.  Yates,  of  Milwaukee,  with  Dr.  C.  H.  Bunt- 
ing,2  of  Madison,  isolated  and  definitely  identified  an  organism  which, 
in  February,  1912,  they  named  B.  hodgkini.  Bunting  has  been  able 
to  cultivate  it  from  all  fresh  aft'ected  tissue,  wherein  the  histological 
diagnosis  was  positive,  or  where  the  blood  picture  of  the  patient  w^as 
characteristic  unless  that  tissue  had  been  contaminated,  or  had  recently 
been  actively  treated  by  the  .r-rays.  Yates^  defines  a  group  of  the 
closely  related  affections  of  w^hich  Hodgkin's  disease  may  be  taken  as  a 
most  characteristic  example  as 

"A  non-communicable  infectious  granulomatous  process  due  to  B. 
hodgkini  (or  to  similar,  but  as  yet  undifferentiated  microorganisms), 
protein  in  the  resultant  local  (tissue)  and  general  reactions,  and  there- 
fore in  clinical  manifestations.  He  differentiates  these  groups  in  the 
following  manner: 

*  Coplin:  Manual  of  Pathology,  p.  448. 

*  J.  L.  Yates  and  C.  H.  Bunting:  John  Hopkins  Hosp.  Bull.,  vol.  xxvi,  No.  297. 

3  J.  L.  Yates:  Johns  Hopkins  Hosp.  Bull.,  November,  1915,  vol.  xxv.  No.  280. 
Colorado  Medicine,  February,  1916. 


DISEASES  OF  LYMPH  NODES  OF  THE  MOUTH  429 

Grouj)  1.    Type,  Hodgkin's  disease. 
Group  2.     T\'pe,  lympliosarcoma. 

(iroup  3.     Type,  l}7nphatic'  leukemia,  pseudoleukemia,  chloroma. 
Group  4.     Type,  chloroma,  Banti's  disease. 
Group  5.     TjqDe,  chronic  hypertrophic  arthritis. 
Group  6.     T^-pe,  elephantiasis-like  cellulitis. 
Group  7.     Type,  mycosis  fungoides. 
The  common  factors  in  these  diseases,  as  we  have  observed  them, 
are  in  brief  as  follows: 

1.  The  presence  (or  history)  of  a  primary  focal  inflammatory  lesion, 
usually,  but  not  necessarily,  in  the  upper  part  of  the  digestive  or  of  the 
respiratory  tract  (teeth,  tonsils,  adenoid  tissue,  sinuses,  bronchi). 

2.  Progressive  enlargement  of  the  l\Tnph  nodes,  with  or  without 
accessory  extranodal  tumors. 

3.  Chronic  course,  with  late  moderate  secondary  anemia  and  with 
the  constant 'development  of  a  fever,  usually  of  an  irregularly  inter- 
mittent character,  exceptionally  of  the  Murchison  type. 

4.  Eventual  fatal  termination  within  a  relatively  brief  period  of 
years  (two  to  five). 

5.  The  occurrence  during  the  course  of  the  disease  of  either  the 
blood  picture  described  by  Bunting  as  the  primary  blood  picture  of 
Hodgkin's  disease,  or  of  a  leukemic  blood  picture. 

6.  The  occurrence  of  a  primary  lesion  in  the  germinal  centers  leading 
to  an  early  loss  of  architecture  in  the  lymph  nodes  through  an  extensive 
proliferation  of  diverse  cells  but  with  common  factors  in  the  picture. 

7.  The  constant  occurrence  in  the  lesions  (nodal  and  extranodal) 
of  organisms  of  the  diphtheroid  t}^e. 

Symptoms. — Usually  the  enlargement  of  cervical  IjTnph  nodes  first 
appears,  and  clusters  of  these  become  prominent  in  a  short  time. 
They  may  be  in  more  or  less  isolated  masses  or  completely  surround 
the  neck.  The  axillary  and  inguinal  glands  next  follow.  Internal 
nodes  may  also  be  involved.  The  spleen,  thymus  and  th}Toid  bodies, 
liver,  pancreas  and  suprarenal  capsule  may  become  involved.  In 
rare  cases  lymphoid  growths  occur  in  the  central  nervous  system 
(Figs.  254  and  255). 

Treatment. — First,  elimination  of  the  portal  or  portals  of  entry 
of  the  infection  (inflamed  tonsils,  teeth,  accessory  sinuses,  dermatitis, 
bronchitis,  enterocolitis,  etc.) ;  second,  wide  extirpation  of  all  eradicable 
involved  tissue;  third,  improved  general  health  through  hygienic 
measures,  present  by  radiation,  immune  serum,  and  medication  any 
extension  of  the  disease,  and  to  repeat  these  treatments  at  intervals  of 
a  few  months. 

Prognosis.- — Yates^  believes  that  by  early  diagnosis,  and  prompt 
radical  treatment  at  least  some  cases  can  be  cured,  and  the  disease 
need  not  necessarily  terminate  fatally. 

1  J.  L.  Yates  and  C.  H.  Bunting:  Jour.  Am.  Med.  Assn.,  March  10,  1917,  pp.  747-751. 


430 


DISEASES  OF  THE  GLANDS 


Tumors  of  the  Ljnnph  Nodes. — ^Lymphangiomas;  Localized  Lym- 
phatic Dilatation. — These  comprise  macroglossia  or  lymphatic  enlarge- 
ments of  the  tongue  and  macrocheilia. 

Varieties. — Lymphatic  nevi,  small  areas  of  colorless  dilated  lym- 
phatics, cavernous  lymphangiomas,  irregular  compressible  tumors 
made  up  of  masses  of  dihited  lymph  vessel  or  a  coalescence  of  several 
dilated  vessels,  and  cystic  hydroma,  commonly  called  hydrocele  of 
the  neck. 


Fig.  254.- 


-Hodgkin's  disease. 
Brewer.) 


(After 


Fig.  255. — Hodgkiu's  disease. 


Etiology. — The  etiology  is  obscm*e.  The  Filaria  sanguinis  hominis 
is  credited  with  being  the  cause  of  certain  forms  of  these  affections. 
Other  forms,  such  as  macroglossia,  hmphatic  enlargement  of  the  tongue 
(page  542),  and  macrocheilia,  lymphatic  enlargement  of  the  lips,  are 
congenital  affections  due  to  lymphatic  obstruction. 

For  further  description  and  treatment  see  page  573. 

Other  Tumors. — Osteomata,  chondromata,  and  endothelioma  occa- 
sionally but  rarely  in\'oh-e  l.Mnph  nodes.  Both  sarcoma  and  carcinoma 
may  affect  the  l\inph  nodes  as  primary  or  secondary  affections.  (The 
important  position  of  the  lymph  nodes  of  the  neck  in  relation  to  malig- 
nant growths  of  the  mouth  is  fully  described  in  consideration  of  these 
affections  on  pages  482,  487  and  489.) 


CHAPTER  VIII. 

TUMORS. 

AccoRDiXG  to  strict  definition  a  tumor  is  a  swelling.  Etymology 
warrants  the  use  of  the  word  tumor  in  this  sense,  and  in  the  past  it  has 
been  somewhat  generally  applied  to  designate  any  abnormal  s\\'elling, 
including  those  of  inflammatory  character  now  termed  infectious 
granulomas  as  well  as  otlier  circumscribed  newgrowths  of  tissue.  At 
present  its  meaning  is  restricted  so  that  the  term  tumor  is  only  used  to 
denote  neoplasms  and  cysts. 

NEOPLASM. 

"Neoplasm  is  a  morbid  growth  characterized  by  a  tendency  to 
persist  or  increase  in  size  independently  of  changes  in  the  metabo- 
lism of  contiguous  or  s}'stematic  structures  and  performing  no  useful 
function."^ 

"  Circumscribed  enlargement  of  a  part  due  to  the  presence  of  morbid 
growth.  "2 

Etiology. — The  vague  attribution  of  tumors  to  humors  of  the  body 
and  of  the  blood  in  the  past  as  well  as  many  more  recent  explanations, 
are  being  rapidly  displaced  in  the  light  of  newer  research.  Experi- 
mentation by  inoculation  of  mice  and  other  animals  and  closer  study 
of  tumors  in  human  beings  is  rapidly  leading  to  a  time  when  the  eti- 
ology' of  malignant  gro^^■ths  may  be  definitely  determined.  At  present, 
however,  there  is  no  known  cause  or  generally  accepted  theory  with 
regard  to  their  origin. 

Virchoics  demonstration  of  his  Jaw,  that  "The  cellular  element  of  the 
tumor  are  derived  from  preexisting  cells  of  the  organism,"  and  MilUers 
Law,  that  "The  tissue  that  forms  the  tumor  has  its  type  in  the  tissues 
of  the  organism  either  adult  or  embyronic,"  are  generally  recognized 
as  fundamental.  With  these  in  view  it  may  be  stated  that  the  follow- 
ing are  the  only  theories  worthy  of  consideration: 

Heredity. — The  many  cases  that  have,  from  time  to  time,  been 
reported  in  \\hich  blood  relations  have  been  affected  by  neoplasms 
of  similar  character  lends  color  to  the  belief  that  there  may  be  an 
inherited  tissue  predisposition  to  malignant  gro^^■ths.  Beyond  this 
there  is  no  evidence  to  prove  direct  heredity. 

Parasitic  Influence. — According  to  the  germ  theories  that  have  been 
advanced,  the  formation  of  malignant  neoplasms  may  be  due  to  an 

1  Coplin:   Manual  of  Pathology,  p.  308.  ^  Duiiglisou's  Medical  Dictionarj-. 

(431) 


432  TUMORS 

animal  parasite  belonging  to  the  protoza  or  a  vegetable  organism 
belonging  to  the  blastomycetes.  Although  neither  of  these  explana- 
tions of  tumor  causation  are  fully  accepted,  the  trend  of  modern 
clinical  pathological  and  experimental  research  appears  to  point  in 
this  direction.  In  support  of  the  belief  that  parasites  of  some  kind  are 
responsible  for  neoplasms  the  following  characteristic  features  of  such 
growths  may  be  noted. 

Local  Infectivity. — Local  infectivity  or  extension  of  cancer  from  one 
part  to  another  when  there  is  contact  of  the  surfaces  is  frequently 
observed.  By  instruments  and  otherwise  the  disease  has  also  been 
extended.  Metastasis  is  generally  recognized  as  equivalent  to  an 
inoculation. 

Inoculation  Experiments. ■ — The  "Jensen  mouse  tujnor"  has  been 
transplanted  thousands  of  times.  Immunity  between  species,  and 
natural,  as  well  as  acquired  immunity  which  have  been  demonstrated 
in  the  course  of  experimentation  are  not  unlike  the  same  conditions 
in  infectious  granulomas. 

Microscopic  Findings. — Gaylord  and  others  have  shown  the  actual 
presence  of  parasites  in  cancerous  growths,  but  microscopic  findings 
which  have  been  reported  favorable  to  the  recognition  of  a  definite 
cancer  parasite  are  not  generally  accepted.  Secondary  invasions 
of  bacteria  into  tumor  growths  frequently  occur  and  confuse  the 
findings  in  this  respect. 

Embryonal  Theory.- — The  embryonal  or  Cohnheim's  theory  pre- 
supposes an  anomalous  embryonic  development  leading  to  the  inclusion 
or  misplacement  of  portions  of  the  original  blastodermic  layer  in  the 
midst  of  tissues  derived  from  a  different  layer  of  the  embryo — the 
so-called  embryonic  rests. 

Certain  forms  of  tumor,  notably  ovarian,  parotid,  and  dermoid, 
seem  to  bear  out  the  truth  of  this  theoretical  explanation,  but  others 
do  not,  and  it  does  not  explain  the  proliferation  of  the  embryonal  rests. 

Irritation  and  Trauma. — Whatever  the  true  cause  may  be,  the  fact 
remains  that,  clinically,  tumors  are  found  to  appear  so  frequentl}'  in 
the  sites  of  previous  traumatic  injuries  and  tissues  subjected  to  long- 
continued  irritation  or  chronic  inflammation  that  every  surgeon  must 
be  convinced  of  the  important  relation  of  such  factors. 

Classification. — In  the  absence  of  full  knowledge  of  the  etiology 
of  tumors  the  various  classifications  that  have  from  time  to  time  been 
presented  by  authors,  founded,  as  they  have  been,  upon  not  fully 
justified  theories  of  origin,  character,  and  development,  are  unwar- 
ranted in  the  opinion  of  the  more  recent  writers  on  pathology,  notably 
Coplin  and  Stengel.  Based  upon  Miiller's  law,  "The  tissue  that 
forms  the  tumor  has  its  type  in  the  tissues  of  the  organism,  either  adult 
or  embryonic."  Coplin  suggests  the  tentative  classification,  according 
to  the  resemblance  of  tumors  to  normal  tissues  shown  on  p.  434. 

Pathology. — Most  tumors  live  at  the  expense  of  the  organism  and 
add  nothing  to  its  development  or  nutrition.     A  few  possible  exceptions 


NEOPLASM  433 

are  noted  in  attempts  at  milk  formation  in  cancer  of  the  breast,  biliary 
pigment  formed  in  carcinoma  of  the  liver  and  glycogen  found  occa- 
sionally in  large  quantities  in  some  tumors.  These  are  assumed  to  be 
functional  attempts.  The  disturbance  of  general  health  is  explained 
as  being  possibly  due  to  interference  with  organic  function,  secondary 
inflammatory  changes,  and  the  absorption  of  noxious  products,  but 
all  of  these  features  will  be  to  some  extent  matters  of  conjecture  until 
the  true  etiology  of  tumors  is  understood. 

Primary  tumors  are  original  growths.  Secondary  tumors  are  metas- 
tatic extensions. 

Tumor  enlargement  or  extension  takes  place  by  (a)  Interstitial, 
by  proliferation  of  its  cells  uniformly  within  the  tumor.  (6)  Dis- 
semination,  which  may  be  (1)  growth  by  infiltration  or  extension  of 
the  tumor  in  surrounding  tissue,  usually  the  lymph  spaces  and  without 
a  sharply  defined  border;  (2)  by  metastasis. 

Metastasis. --The  transplantation  of  a  tumor  from  one  part  of  the 
body  to  another  may  take  place  through  lymphatic  or  venous  channels 
and  extend  for  considerable  distance  along  the  lines  of  their  distribution. 
Tumor  cells  may  be  carried  as  emboli  along  the  lymphatic  or  venous 
channels,  to  result  in  a  secondary  growth  in  some  new  location,  or  a 
tumor  may  spread  over  membranous  surfaces  such  as  the  peritoneum, 
pleura,  and  occasionally  mucous  membrane  surfaces  to  form  new  foci 
at  various  points. 

Benign  tumors  have  been  known  to  recur  after  removal,  as  in  cases 
of  nasal  polypi  and  keloids  of  the  skin,  or  to  cause  primary  tumors  or 
metastasis  as  in  adenomas,  chondromas,  and  leiomyomas. 

Pigmentation  results  from  hemorrhage  within  the  tumor  and  dis- 
integration of  the  blood-coloring  matter,  or  may  be  due  to  pigment- 
producing  cells,  as  in  a  chloroma,  melanotic  sarcoma,  etc.  It  is  also 
claimed  to  be  due  to  certain  bacteria  when  tiunors  are  ulcerated. 

Diagnosis. — In  a  general  way  the  clinical  distinctions  between  benign 
and  malignant  growths  are  as  follows: 

MALIGNANT.  BENIGN. 

Rapidity    of    growth.  Grows  slowly. 

Invasion  by  infiltration,  -n-ith  tendency  Does    not    extend    by    infiltration    or 

to  break  down  surrounding  tissues.  invasion  of  surrounding  structures.  (Most 

benign  tumors  are  circumscribed  but  a 
few,  such  as  lipomata,  may  be  diffuse.) 

Recurrence  after  removal.  Does    not    usually    recur    when    com- 

pletely removed. 

Formation  of  metastases.  Practically  no  tendency  to  metastasis. 

Tendency  to  produce  cachexia.  Does  not  cause  cachectic  conditions. 

General  Form  for  Diagnostic  Description  of  Tumors. — Situation, 
formation,  size,  number,  consistence,  color,  mobility,  sensibility, 
influence,  if  any,  upon  surrounding  structures;  history  of  growth; 
history  of  patient  (age,  sex,  social  condition,  occupation,  habits,  hered- 
ity, general  nutrition),  and  previous  history  of  the  organ  or  tissue 
involved. 
28 


434 


TUMORS 


Tumors  (Those  in  Italics  Are  Malignant). 


Tumors 


Neoplasms 


Epithelial 
(epiblast 
and  hypo- 
blast) 


Cysts     ' 


Adult    (typi- 
cal benign) 


Embryonic 

(atypical, 

malignant) 


Connec- 
tive tissue 


blast) 


Adult       (typi- 
cal or  be- 
nign) 


Embryonic 
(atypical 
malignant) 


-Teratoma 


Papilloma 


Adenoma 


Glioma 


Carcinoma 
or  Cancer 


Lipoma 
Chondroma 

Osteoma 


Fibroma 


Myoma 


Angioma 


Lympho- 
ma (?) 
Myxoma 


Sarcoma 


Skin  warts. 
Villous  warts. 
Intracystic  warts. 
Acinous. 
Tubular. 

Ganglionic  neuroma. 
Mj'elinic  neuroma. 
Amyelinic  neuroma. 


Epithelioma 


Glandular 


Simple. 
Fibrous. 

Eburnated. 

Compact. 

Spongy. 

Simple 


Squamous. 
Tubulated. 
Cylindric. 

Scirrhus. 

Encephaloid 

(Colloid, 

Mucoid, 

Melanotic). 


Hard. 
Soft. 


Fibroma  molluscum. 

Keloid. 

Leiomyoma  (unstriped). 

Rhabdomyoma    (striped) 

Hemangioma  [  Simple. 

(blood-         -s  Cavernous. 

vessels)  {  Plexiform. 

Lymphangioma 

(lymph  vessels). 

/  Large. 


Round-cell 


Spindle-cell 


\  Small. 
Large. 
Small. 


Myeloid. 

Mixed-cell. 

Alveolar. 

Melanotic,  cystic,  etc. 


Mixed 

(both  epithelial  and  connective  tissue). 

(1)  Retention  (occluded  excretory  ducts). 

(2)  Exudation  (accumulations  in  closed  cavities). 

(3)  Cystomas  (new  formation). 

(4)  Extravasation  (those  forming  from  extravasations). 

(5)  Dermoid  (congenital  and  due  to  inversion  of  the  cutis  and  to  imper- 

fectly closed  fetal  clefts). 

(6)  Parasitic  (due  to  animal  parasites). 

(7)  Cysts  resulting  from  necrotic  and  degenerative  changes. 


CYSTOMAS. 

A   cyst  consists  of  a  connective-tissue  membrane  or    supporting 
wall  lined  by  epithelium  or  endothelium  and  forming  a  cavity,  the 

1  Coplin:  Manual  of  Pathology,  p.  366. 


CYSTOMAS  435 

contents  of  which  may  be  fluid  or  semifluid,  uniform  in  composition 
or  made  up  of  a  mixture  of  similar  or  dissimilar  substances.  Cysts 
are  described  as  simple  or  unilocular  when  single,  and  multiple  cysts 
when  there  are  several  cysts  together,  which  are  identical  in  cause  and 
structure. 

Proliferous  cysts  are  those  in  which  the  cyst  walls  continue  to  spring 
from  each  other  or  proliferate. 

Mvltilocvlar  is  the  term  applied  to  those  in  which  a  number  of  cysts 
together  remain  distinct,  cavernous,  to  those  that  communicate. 

Papilliferous  cysts  are  lined  with  papillomatous  masses. 

Classification. — (1)  Retention  cysts,  due  to  the  occlusion  of  excretory 
ducts  of  glands.  (2)  Exudation  cysts,  caused  by  accumulations  in 
cavities  not  supplied  by  excretory  ducts,  as  bursse,  tendon  sheaths,  etc. 
(3)  Cystoma,  a  cyst  that  is  the  result  of  a  new  formation.  (4)  Extrav- 
asation cysts,  those  formed  around  distended  or  ruptured  vessels. 
(5)  Dermoid  .cysts,  congenital  cystic  results  of  cutaneous  inclusion, 
or  inclusion  of  a  blighted  ovum.  (6)  Parasitic  cysts,  caused  by  animal 
organisms,  as  trichinse  and  other  parasites.  (7)  Cysts  resulting  from 
necrotic  and  degenerative  changes  in  solid  tissues,  such  as  those  formed  in 
neoplasms  from  hemorrhage  liquefaction,  necrosis,  and  other  forms 
of  softening,  as  well  as  other  degeneration  processes. 

Retention  Cysts. —  Cysts  of  the  Mucous  Glands. — Etiology. — Occlu- 
sion of  the  ducts  of  these  glands  from  inflammatory  or  other  causes 
leads  to  cystic  formation. 

Symptoms. — The  cysts  appear  on  the  inner  side  of  the  lips  and  cheeks 
and  on  the  under  surface  of  the  tongue.  In  the  beginning  they  are 
quite  small,  but  by  constant  accumulation  of  fluid  may  extend  until 
they  become  as  large  as  a  walnut.  They  vary  from  pink  to  bluish 
color,  and  give  very  little  disturbance  unless  through  enlargement 
they  occasion  inconvenience  by  interference  with  movements  of  the 
tongue  or  occlusion  of  the  teeth. 

Diagnosis. — These  cysts  are  differentiated  from  hemangioma 
because  they  are  more  localized  and  the  color  is  not  so  dark  a  blue; 
from  l,>Tnphocysts  because  the  latter  are  more  irregular  in  form  and 
there  is  a  distinct  difference  in  their  contents.  The  author's  cases 
have  usually  given  history  of  these  cysts  having  been  more  or  less 
frequently  opened  or  ruptured  with  immediate  disappearance  and 
later  recurrence. 

Treatment. — ^The  author's  method  of  treatment  of  mucous  cysts 
is  to  inject  2  per  cent,  solution  of  cocain  into  the  surrounding  tissue. 
He  then,  grasps  the  mucous  membrane  close  to  the  border  of  the  cyst 
with  a  forceps,  to  carefully  follow  its  outline  in  dissection  until  the  cyst 
is  removed  in  its  entirety  without  rupture  of  its  thin  membranous  wall. 
Such  a  cyst,  even  of  large  size,  when  removed,  should  remain  intact, 
and  it  should  be  possible  to  hold  it  in  the  palm  of  the  hand  with  its 
perfect  form  complete.  When  this  is  done  there  is  absolute  certainty 
of  the  removal  of  the  entire  cyst,  and  there  is  no  possibility  of  its  recur- 


436  TUMORS 

rence.    The  mucous  membrane  edges  of  the  wound  surfaces  are  drawn 

together  and  sutured  with  gut  sutures.  The  operation  thus  performed 
is  painless  and  gives  practically  no  inconvenience  by  reason  of  the  few 
sutures  that  are  necessary.  With  the  continued  use  of  mouth  washes 
the  healing  takes  place  readily  without  formation  of  troublesome  scars. 
Other  methods,  such  as  cauterization  and  curettement,  are  usually 
less  effective  and  sometimes  more  troublesome. 

Deep-seated  Cysts  of  the  Mucous  Glands. — Deep-seated  cysts  of  the 
mucous  glands  of  the  tongue  arising  near  the  foramen  cecum  and  the 
third  tonsil  sometimes  have  long  excretory  ducts,  and  these  cause 
enlargement  of  the  parts  that  may  be  less  easily  distinguished  because 
the  symptoms  are  sometimes  quite  similar  to  those  of  hypertrophy 
of  the  lingual  tonsil.  Through  contact  with  the  epiglottis  they  may 
cause  irritation  and  give  rise  to  a  cough  easily  mistaken  for  a  symptom 
of  some  other  affection. 

BicKjnosis. — ^The  laryngeal  mirror  is  necessarj''  for  diagnosis  of  these 
cysts. 

Treatment. — Their  removal  is  effected  by  extirpation  or  cauteri- 
zation, whichever  may  be  indicated  by  the  conditions  of  the  case. 

Cysts  of  the  Glands  of  Blandin-Nuhn. — These  sometimes  appear  on 
the  tip  of  the  tongue. 

Symptoms. — ^This  form  of  cyst  is  rare  and  appears  on  the  tip  of  the 
tongue,  is  quite  transparent,  covered  with  pale  red  mucosa,  and  may 
become  so  large  as  to  be  an  inch  or  more  in  circumference. 

Treatment. — The  same  as  described  for  mucous  cysts. 


Fig.  256. — Ranula. 

Ranula  (Frog  Tongue,  Sublingual  Cyst). — ^This  is  a  cyst  situated  under 
the  tongue.  The  term  ranula,  as  commonly  used,  may  be  defined  as  a 
cyst,  situated  under  the  tongue  l)etween  the  frenum  and  the  point  of 
the  jaw  which  displaces  the  tongue  upward.  Protest  has  been  made 
by  many  authors  against  the  use  of  this  term  to  include  mucous  and 
other  retention  cysts  in  this  region,  and  all  agree  that  it  should  be 
confined  to  cysts  of  the  sublingual  or  submaxillary  glands. 


CYSTOMAS  437 

Etiology. — A  ranula  may  be  congenital  and  due  to  some  failure 
of  development  of  the  duct  of  the  gland,  or  occlusion  of  the  duct  may 
occur  at  any  period  in  life  from  inflammatory  processes. 

SymjJtoms. — In  the  early  stages  the  swelling  is  confined  to  one  side 
with  the  tongue  correspondingly  displaced.  As  the  ranula  extends 
in  size  it  sometimes  includes  the  opposite  side  of  the  mouth,  and  the 
swelling  also  appears  beneath  the  jaw  and  chin.  It  may  be  pink 
or  grayish  in  color,  having  the  appearance  of  a  bladder  with  the  vessels 
in  a  thin  distended  wall  quite  marked.  These  cysts  are  usually  filled 
with  a  light  more  or  less  viscid  fluid,  but  this  may  vary  under  some 
conditions  to  dark  bro\\Ti  color  or  may  even  be  tinged  with  green  or  red 
(Fig.  256) .  They  grow  slowly  and  give  a  little  disturbance,  except  as 
size  increases.  Sometimes  a  ranula  may  become  so  large  as  to  interfere 
with  speech  and  the  use  of  the  tongue;  in  rare  instances  it  may  cause 
difficulty  in  breathing.  Large  ranula  in  young  children  may  alter  the 
form  of  development  of  the  jaws. 

Diagnosis. — ^True  ranula  may  be  differentiated  from  mucous  cysts 
of  the  floor  of  the  mouth  and  tongue  by  difference  in  situation;  from 
solid  tumors,  such  as  lipoma,  angioma,  and  lymphangioma,  or  the  more 
solid  gro\\1;hs,  by  difference  in  consistency  as  well  as  appearance  and 
mobility,  for  most  tumors  become  more  or  less  adherent.  With  one 
finger  placed  within  the  mouth  under  the  tongue  over  the  cyst  and 
another  upon  the  external  surface  under  the  jaw  below  it  the  free 
movability  and  fluctuation  of  the  mass  which  can  then  be  felt  usually 
serves  to  make  these  distinctions  quite  evident.  Confusion  in  diag- 
nosis may  occur  when  a  dermoid  cyst  is  situated  just  under  the  sub- 
maxillary gland  and  displaces  it  with  the  floor  of  the  mouth  and  tongue 
upward  in  much  the  same  way  that  these  parts  are  displaced  by  ranula, 
and  the  swelling  may  be  so  great  as  to  make  it  difficult  to  manipulate 
the  tumor  within  the  mouth  sufficiently  to  make  an  exact  differentia- 
tion.    Such  a  case  is  described  on  p.  443  and  illustrated  (Fig.  263). 

Prognosis. — ^These  cysts  are  benign  and  the  question  of  their  recur- 
rence is  largely  dependent  on  the  success  of  the  method  of  treatment. 

Treatment. — Complete  extirpation  of  the  ranula  when  not  too  large 
may  be  accomplished  from  within  the  mouth,  as  described  for  large 
mucous  cysts.  When  the  ranula  is  of  large  size  and  the  surrounding 
parts  correspondingly  displaced,  it  is  sometimes  much  better  to 
remove  it  by  an  external  incision  below  the  jaw.  When  extirpation 
is  not  advisable  the  ranula  may  be  opened  and  the  cyst  wall  destroyed 
by  curettement.  Further  destruction  may  be  accomphshed  with 
carbolic  or  nitric  acid,  and  packing  to  encoiu'age  granulation  from  the 
bottom  of  the  wound  to  prevent  reestablishment  of  the  cyst  wall. 

The  author's  method  of  treating  ranula  (a  modification  of  the  plan 
suggested  by  Deguise)  is  really  very  simple. 

Touching  the  mucous  membrane  on  each  side  of  the  swelling  with 
cocain  makes  the  passing  of  a  needle  through  from  one  side  to  the  other 
quite  painless.     A  wire  is  thus  drawn  through  and  a  loop  formed  by 


438 


TUMORS 


bringing  the  ends  together  and  fastening  with  a  compressed  shot.  The 
loop  is  bent  into  such  form  as  to  give  the  least  possible  inconvenience 
to  the  tongue.  The  natural  movement  of  the  tongue  is  sufficient  to 
keep  the  wire  loop  moving  slightly  so  that  in  the  course  of  time  the 
holes  made  by  the  wire  become  permanent  and  thus  continue  to  serve 
the  purpose  of  ducts  after  the  wire  is  removed.  Other  methods  of 
treatment  are  sometimes  very  troublesome.     The  almost  immediate 


Fig.  257. — Illustration  of  a  ranula  with  wire  loop  in  place  as  described  in  the  text, 
and  performed  in  the  case  of  a  young  girl,  aged  ten  years  and  other  cases.  Although  this 
girl  had  been  operated  upon  several  times  before,  the  ranula  never  appeared  again  after 
insertion  of  the  wire  loop. 


recurrence  of  the  swelling,  after  it  has  been  incised,  the  danger  o  isevere 
hemorrhage,  or  distressing  swelling  after  cauterization,  and  other  irri- 
tating procedures  are  serious  considerations.  For  example,  a  man  who 
had  been  previously  treated  for  several  months  without  relief,  was 
brought  to  the  author,  after  having  suffered  an  almost  uncontrollable 
hemorrhage  incident  to  an  attempt  to  destroy  the  cyst  by  the  actual 
cautery.  In  two  or  three  minutes  the  wire  loop  was  placed,  the 
swelling  immediately  disappeared,  and  never  recurred.    Some  months 


CYSTOMAS  439 

later  the  wire  was  removed.  Another  patient,  a  girl  about  ten  years 
old,  was  relieved  instantly  and  painlessly  by  the  same  treatment.  In 
this  case  because  of  frequent  recurrence  malignancy  had  been  sus- 
pected.    (See  Fig.  257.) 

Periosteal  Cysts  of  the  Jaws. — Etiology. — These  cystic  cavities  occur 
in  connection  with  roots  or  parts  of  roots  of  teeth,  or  in  sites  that 
have  formerly  been  affected  by  dento-alveolar  abscess  from  which 
the  offending  tooth  root  may  have  been  extracted,  but  with  the  cavity 
in  the  bone  too  large  to  allow  sufficient  drainage,  and  thus  it  has 
become  filled  with  fluid.  In  recent  years  there  has  been  much  inves- 
tigation of  the  degenerative  processes  whereby  ephitheliated  granu- 
lomata  become  cysts  through  concentric  degeneration  of  the  inner 
part  of  the  granuloma,  and  a  development  and  proliferation  of  the 
epithelium  due  to  chronic  inflammatory  conditions.  Undoubtedly 
this  occurs,  but  all  granulomata  do  not  necessarily  form  cysts.  Their 
contents  may  be  pus,  serum,  or  blood  if  a  bloodvessel  in  connection 
with  the  cystic  formation  has  lost  its  integrity  sufficiently  to  allow 
escape  of  blood  that  is  retained  within  the  walls  of  the  cyst,  thus  prac- 
tically converting  it  into  a  hematoma. 

An  example  of  this  type  of  blood-filled  cyst  of  the  jaws  is  given 
in  Fig.  258.  The  history  of  this  cystic  tumor  of  the  lower  jaw  of  a 
young  man,  aged  twenty  years,  is  as  follows:  The  exact  time  and 
character  of  its  origin  was  not  known.  It  had  been  gradually  forming 
and  increasing  in  size  for  many  years.  Several  unsuccessful  operations 
had  been  performed  for  its  removal.  For  five  years  past  it  had  been 
opened  at  intervals  to  allow  the  escape  of  fluid  contents.  This  gave 
temporary  relief,  but  in  a  short  time  there  was  a  recurrence.  Wasser- 
mann  was  negative,  and  there  was  no  unusual  blood  picture  except 
slight  indication  of  anemia,  doubtless  due  to  continued  loss  of  blood. 
At  the  operation  a  complete  extirpation  was  performed.  The  cyst 
and  the  cyst  walls  including  the  external  thin  bony  covering  on  the 
buccal  side  as  well  as  most  of  the  bone  on  the  lingual  side  of  the  jaw 
were  removed  from  an  area  extending  from  the  ramus  a  little  above 
the  angle,  to  the  first  bicuspid  region  on  the  opposite  side.  The 
hemorrhage  was  very  profuse,  but  was  easily  checked,  and  the  entire 
surface  was  cleared.  The  form  of  the  jaw  was  retained  by  a  con- 
tinuous packing  with  gauze  until  new  bone  formation  gave  sufficient 
rigidity,  as  shown  in  Fig.  259.  Undoubtedly  the  periosteum,  which  had 
been  carefully  preserved,  was  an  important  factor  in  this  restoration. 

The  most  common  location  of  cysts  of  this  character  is  in  the  region 
of  the  roots  of  the  upper  lateral  incisors,  but  any  part  of  either  jaw 
may  be  similarly  affected.  By  far  the  vast  majority  of  the  hundreds 
of  cases  sent  to  the  author  for  surgical  treatment  of  these  cysts  have 
been  more  or  less  directly  the  result  of  septic  conditions  of  the  lateral 
incisors.  Pulp  devitalization  from  traumatism,  pulpitis  due  to  ex- 
posure by  caries,  or  other  causes,  lead  to  septic  conditions  that  ulti- 
mately involve  the  anterior  part  of  the  upper  jaw,  in  which  immedi- 


440  TUMORS 

ately  posterior  to  the  incisor  teeth  there  are  the  anterior   palatine 
foramina  and  surrounding  cancellous  bone  structure. 


Fig.  258. — Radiograph  of  a  cyst  of  the  lower  jaw. 


Fig.  259. — The  young  man  for  whom  the  cyst  illustrated  in  Fig.  258  and  described 
in  the  text  was  removed.  The  marks  indicate  the  extent  of  the  jaw  involvement  with 
the  exception  of  a  little  bone  surrounding  the  anterior  teeth;  nearly  all  of  the  affected 
portion  of  the  jaw  was  removed.  There  has  been  almost  complete  bone  regeneration. 
The  outline  of  both  sides  of  the  jaws  is  symmetrical. 

Treatment  such  as  applied  by  dentists  through  the  flat,  curved, 
or  tortuous  root  canals  of  these  teeth  is  insufficient,  or  it  may  be  that 
the  condition  has  been  neglected,  or  there  may  have  been  failure  to 


CYSTOMAS  441 

make  diagnosis  of  a  dead  pulp  caused  by  a  blow  where  there  happened 
to  be  no  carious  cavity  to  lead  to  its  discovery. 

Symptoms.- — Such  cysts  are  painless  in  the  absence  of  acute  inflam- 
matory snnptoms.  They  grow  slowly  with  gradually  increasing 
thinness  of  the  bony  walls  which  occasionally  bulge  out  into  the 
mouth  in  marked  degree.  Sometimes  such  cysts  extend  into  the 
cavity  of  the  maxillary  sinus,  or  may  similarly  involve  the  nose  and 
other  surrounding  parts  (Fig.  258). 

Diagnosis. — The  history  of  the  case  usually  makes  the  diagnosis 
simple.  There  may  have  been  devitalized  teeth  or  roots  in  the 
vicinity  of  the  cyst,  discolored  teeth  without  carious  cavities  that  indi- 
cate septic  pulp  chambers,  history  of  traumatic  injury  of  teeth  that 
have  been  previously  diseased  even  though  treated,  and  roots  filled  or 
extracted.  Quite  frequently  there  is  history  of  repeated  swelling 
and  discharge  of  contents  of  the  cyst  and  enlargement  by  outward 
extension  of  the  bony  wall,  which  is  usually  thin  and  yields  upon 
pressure.  There  may  or  may  not  be  a  crackling  sound,  according  to 
the  condition  of  the  overlying  vascular  supply  of  the  bone  surface. 
A  radiogram  makes  diagnosis  definite. 

Treatment. — The  treatment  lies  in  removal  of  the  cause.  Destruc- 
tion of  the  cyst  wall,  preferably  with  a  dental  or  surgical  engine  bur, 
thorough  curettement  and  packing.  The  advisability  of  extraction 
or  treatment  of  the  diseased  root  by  amputation  of  its  apical  portion, 
and  filling  the  root  canal  after  methods  well  known  to  all  dentists,  is  a 
question  that  necessarily  depends  upon  the  judgment  of  the  operator. 
The  retention  of  teeth,  especially  in  the  anterior  part  of  the  mouth, 
is  a  matter  of  importance.  In  many  cases,  however,  their  ultimate 
removal  is  necessary  to  prevent  recurrence  of  the  condition. 

Follicular  Odontomas. — These  are  also  known  as  dentigerous  cysts 
and  are  described  on  page  445,  in  connection  with  odontoma. 

Proliferous  or  Proliferation  Cysts. — These  terms  are  used  to  describe 
formations  more  closely  analogous  to  true  tumors  than  other  forms  of 
cysts.  These  growths  may  appear  in  any  of  the  glandular  organs, 
but  most  frequently  affect  the  mammary  gland  and  ovary.  The  cyst 
cavity  contains  serous  or  gelatinous  fluid,  sometimes  called  colloid 
material,  and  occasionally  the  contents  are  hemorrhagic  in  character. 
The  inner  lining  of  the  cyst  may  be  smooth  or  elevated  irregu- 
larly with  papillary  ingrowths.  For  this  reason  they  are  sometimes 
called  papillomatous  cystomas.  These  cj'sts  may  be  unilocular,  but 
are  usually  multilocular  and  contain  two  or  more  large  cysts  and 
numerous  smaller  cavities.  Reciprocal  pressure  may  cause  more  or 
less  destruction  of  the  septa,  and  numerous  loculi  may  communicate, 
thus  forming  a  cavernous  cyst.  The  cyst  cavities  arei  ined  with 
typical  or  columnar  epithelium  and  a  stroma  or  reticulum  of  con- 
nective tissue. 

Multilocular  Cysts. — Diseased  jroots  of  teeth,  or  follicular  odon- 
tomas, may  give  rise  to  a  form  of  cyst  made  up  of  many  similar  c^'sts. 


442 


TUMORS 


These  sometimes  attain  an  enormous  size  (Figs.  260  and  261),  which 
the  author  is  able  to  show  tlirough  the  courtesy  of  Dr.  Westmoreland, 
of  Atlanta.  In  this  case  the  multilocular  cyst  originated  from  a 
dentigerous  cyst.  These  cysts  are  the  result  of  embryonic  inclusion 
of  epithelial  cells. 

Diagnosis. — Diagnosis  of  this  variety  of  cysts  is  simple,  but  the 
nature  of  these  growths  is  not  so  well  understood. 

Pro  gnosis. ^They  are  close  upon  the  border  of  the  malignant  growths. 
The  tendency  to  continued  proliferation  and  growth  after  incom- 
plete removal  renders  such  cysts  a  menace.  McCurdy  wisely  calls 
attention  to  the  fact  that  proliferating  cystomas,  unless  completely 
removed,  even  when  the  remaining  cj'sts  may  be  almost  microscopic, 
may  cause  recurrence,  and  that  in  such  cases  a  wide  and  complete 
operation  is  necessary. 


Fig.  260. — Miiltilocular  cyst. 
(Westmoreland.) 


Fig.  2G1. — Mululocular  cyst. 
(Westmoreland . ) 


Treatment. — Removal  should  be  as  complete  and  effective  as  pos- 
sible, and  a  large  area  of  bone  and  surrounding  soft  tissue  removed 
beyond  the  outline  of  the  cyst  when  its  size  and  situation  will  permit 
this  to  be  done.  Total  resection  of  the  involved  division  of  the  jaw- 
is  recommended  by  many  surgeons. 

Dermoid  Cysts.— Dermoid  cysts  are  congenital  cysts  caused  by 
cutaneous  inclusion  or  the  inclusion  of  a  blighted  ovum. 

Symptoms. — They  are  found  in  many  parts  of  the  body,  such  as 
the  ovary,  base  of  the  brain,  neck,  etc.  Our  interest  centers  in  those 
that  are  found  in  the  neck,  tonsils,  phar\-nx,  hard  and  soft  palates, 
the  floor  of  the  mouth,  and  dorsum  of  the  tongue.  They  vary  con- 
siderably in  size.  On  account  of  the  epithelial  lining  of  the  cyst, 
hair,  teeth,  and  sweat  glands  are  not  unusual  contents.     According 


CYSTOMAS  443 

to  Brummell/  the  hair  may  be  several  feet  long,  and  it  is  usually  of 
light  brown  color.  He  also  claims  that  it  whitens  as  the  outer  hair 
becomes  white.  Occasionally  they  contain  bone  and  cartilage,  an 
indication  that  connective-tissue  products  are  also  present,  which 
points  to  fetal  occlusion.  These  are  called  compound  dermoids,  to 
distinguish  them  from  simple  dermoids,  in  which  no  connective-tissue 
elements  are  present,  and  Coplin  believes  this  form  should  entitle 
them  to  be  classed  with  teratomas. 

Quite  frequently  the  cyst  wall  is  very  thin  (Fig.   262),  and  filled 
with  more  or  less  oilv  contents. 


Fig.  262. — Portion  of  a  wall  of  an  ovarian  dermoid  cyst;  a,  wall  of  the  cyst;  h,  projecting 
portion  made  up  of  fatty  and  cutaneous  tissue;  c,  hairs;  d,  teeth.     (Ziegler.) 

The  tumor  shown  in  Fig.  263,  before  removal  by  the  author,  is 
interesting  because  it  illustrates  the  difficulties  of  diagnosis  that  some- 
times occur  in  these  cases.  The  situation  of  the  tumor  was  such  as 
to  force  the  floor  of  the  mouth  and  the  inferior  maxillary  gland  up 
until  the  tongue  was  almost  completely  turned  over  to  the  other  side 
of  the  mouth.  A  history  of  what  was  claimed  to  be  surgical  removal 
(an  error,  of  course,  because  whatever  other  structures  may  have 
been  operated  upon  the  growth  itself  was  not  disturbed)  and  recur- 
rence complicated  the  diagnosis.  Palpation  within  the  mouth  was 
difficult  on  account  of  displacement.  The  submaxillary  gland  could 
be  felt  close  to  the  surface,  and  for  a  time,  in  view  of  the  history  given, 
it  was  thought  to  be  a  tumor  of  this  gland.  Incision  following  the 
lower  border  of  the  jaw  and  another  one  just  anterior  to  the  sterno- 
cleidomastoid muscle  made  it  possible  to  expose  the  mass  and  enucleate 
the  cyst  with  little  difficulty.  Recovery  was  complete  and  uninter- 
rupted. 

»  Dental  Cosmos,  1905. 


444  TUMORS 

Prognosis. — These  cysts  are  chiefly  of  interest  because  of  their 
possible  explanation  of  unusual  conditions  that  from  time  to  time 
arise  in  and  around  the  buccal  cavity.  But  they  are  benign,  and 
except  when  of  large  size  and  in  dangerous  situations  removal  is  a 
comparatively  simple  matter. 


Fig.  263. — Dermoid  cyst  of  the  neck. 

Parasitic  Cysts.— Echinococcus  Cysts. — In  rare  instances  hydatid 
cysts  have  been  found  in  the  mouth  caused  by  Taenia  echinococcus 
or  dog  tapeicorm.  These  usually  gain  entrance  in  the  intestinal  tract, 
and  in  rare  instances  form  cysts  in  the  buccal  mucous  membrane. 

Bertela  and  others  report  finding  these  cysts  in  the  temporal  and 
masseter  muscles.^ 

ADULT   EPITHELIAL   TUMORS. 

Odontoma.^ — An  odontoma  is  a  tumor  composed  of  one  or  more 
of  the  dental  tissues  arising  either  from  tooth  changes  or  teeth  in 
process  of  development. 

Etiology. — The  causes  are  perversion  of  development  leading  to 
diversion  of  the  structures  or  cellular  elements  from  which  tooth 
germs  are  developed  resulting  in  abnormality  of  form  and  character 
through  which  several  kinds  of  tumors  occur. 

Classification. — Broca  divides  odontomas  according  to  the  stage  of 
development  of  the  dental  follicles  at  which  they  occur.  In  the  first 
or  emhryo'plastic  stage  the  tumor  developing  in  the  dental  sac  when 
the  latter  is  composed  of  mucous  tissue  results  in  a  pure  myxoma. 
When  connective  tissue  is  included  it  results  in  a  fibrous  odontoma. 

In  the  second  or  odontoblastic  stage  soft  tumors  may  occur,  but 
these  have  a  tendency  to  become  hardened. 

The  third  period  results  in  tumors  the  composition  of  which  repre- 

1  Bulletin  of  von  Bergmann,  p.  521. 


ADULT  EPITHELIAL  TUMORS  445 

sents  calcified  tooth  structures.  When  occurring  in  this  stage  the 
tumor  is  composed  of  structure  reseriibhng  calcified  tooth  structures. 
These  are  subdivided  into  crown  and  root  formations,  and  may  be 
still  further  distinguished  by  indicating  whether  composed  of  enamel, 
dentin,  or  cementum,  or  a  composite  combination  of  these. 

Sutton's  classification,  which  will  be  used  in  further  description,  is 
designed  to  distinguish  the  several  forms  of  odontoma.  Clinically 
the  essential  difference  lies  in  differentiation  between  the  forms  which 
result  in  soft  tumors  and  those  of  hardened  tooth  structure,  and  in 
considering  diagnosis  and  treatment  this  general  division  is  the  one 
principally  required. 

Odontoma  forms  a  notable  example  of  the  exceptions  that  must 
necessarily  occur  in  all  timior  classifications,  viewed  in  the  light  of 
our  present  unperfect  knowledge  of  true  etiology.  It  is  true  that  teeth 
are  developed  from  epiblastic  and  mesoblastic  structures,  and  for 
this  reason  odontoma  cannot  be  classified  with  the  epithelial  group 
in  a  strict  sense.  On  the  other  hand,  it  is  of  the  adult  tj-pical  tj-pe, 
and  for  this  reason  it  does  not  seem  advisable  to  classify  it  with  the 
teratoma  or  mixed  epithelial  and  connective-tissue  tumors,  because 
these  are  both  adult  and  embryonic,  whereas  the  odontoma  is  adult 
and  therefore  benign.  Sutton  classifies  the  different  forms  of  odon- 
toma as  follows 

Epithelial  Odontoma. — These  develop  from  the  remains  of  the 
epithelium  of  the  original  enamel  organ. 

Symptoms. — They  appear  in  the  form  of  a  series  of  cysts  sepa- 
rated by  thin  septa  and  contain  mucoid  fluid.  The  color  during 
gro^slh  is  slightly  red  and  not  unlike  sarcoma. 

Follicular  Odontoma  or  Dentigerous  Cysts. — Etiology. — They 
usually  form  in  connection  with  developing  permanent  teeth. 

Symptoms. — The  bony  walls  become  thin  from  the  formation  of 
fluid  within  the  cyst  and  sometimes  bulge  out  in  such  manner  as  to 
cause  great  deformity.  The  inner  wall  of  the  cyst  represents  the 
remains  of  the  dental  follicle  within  which  in  every  instance  there 
is  a  tooth  or  part  of  a  tooth.  The  cyst  is  filled  with  fluid,  usually 
serous  or  mucoid,  but  occasionally  of  dark  bro\^'n  color.  Ordinarily 
these  do  not  become  purulent,  but  occasionally  through  infection  this 
does  occur,  and  may  result  in  severe  inflammatory  conditions  (Figs. 
264  and  265). 

Fibrous  Odontomas. — ^Fibrous  odontomas  are  developed  from 
the  connective-tissue  elements  of  the  developing  tooth  by  excessive 
gro^\-th  of  the  fibrous  capsule  of  the  tooth  germ  which  is  derived 
from  and  closely  adherent  to  the  connective  tissue  of  the  papilla. 

Symptoms. — The  tumor  has  a  firm  outer  wall  with  less  firmly  con- 
nected mner  structure,  which  blends  at  the  root  of  the  tooth  with 
the  dental  papilla  and  is  indistinguishable  from  it.  In  this  way  the 
developing  tooth  becomes  enclosed  within  the  capsule.  These  tiunors 
are  quite  frequently  seen  in  animals,  especially  ruminants,  etc.  (Fig.  266). 


446 


TUMORS 


Cementome. — This  is  a  tumor  in  which  by    calcification  of  the 
capsule  the  tooth  becomes  embedded  in  a  mass  of  cementum. 


Fig.  264. — Cyst  of  the  lower  jaw,  having  its  origin  about  an  undeveloped  tooth. 

(Garretson.) 


Fig.  265. — Denta   cyst,  lower  jaw. 


Symptoms. — Cementomes    sometimes    attain    great    size.    Their 
structure  resembles  cementum,  and  is  arranged  in  layers  somewhat 


ADULT  EPITHELIAL  TUMORS 


447 


similar  to  fibrous  odontomas.  They  are  rare  in  human  teeth  and 
usually  occur  in  the  mammalia.  ^Marshall  reports  a  tumor  in  the 
mouth  of  a  horse  five  and  three-quarters  inches  by  four  and  one- 
quarter  inches  in  size,  which  ultimately  caused  the  death  of  the  animal. 


Fro.   266. — Fibrous   odontome.      (Garret- 
son,  after  Pierce.) 


Fig.  267. — RadicTilar  odontome. 
(Tomes.) 


Fig.  268. — Composite  odontome. 


Fig.  269. — Composite  odontome.     (Gilmer.) 


R-^DicuLAR  Odoxtoma.s. — Thesc  tumors  form  after  the   develop- 
ment of  the  cro^^^l  and  diuing  the  process  of  root  formation.     They 


448 


TUMORS 


consist  of  cementiim  and  dentin  in  varying  quantities,  are  rare  in 
men,  but  frequent  in  animals  (Fig.  267). 

Composite  Odontomas. — ^These  are  abnormal  growths  of  all  the 
elements  of  tooth  structure,  resulting  in  ill-deformed  masses  of  cemen- 
tum,  dentin,  and  enamel.  Thus  far  they  have  only  been  found  in 
man  (Figs.  268  and  269). 

Compound  Follicular  Odontomas. — The  follicle  wall  becomes 
thickened  into  a  fibrous  capsule.  In  this  there  may  be  portions  of 
dentin,  enamel,  or  cementum.  Imperfectly  or  more  or  less  imper- 
fectly formed  teeth  are  all  together  a  heterogeneous  mass.  Fig.  270 
shows  photograph  of  a  compound  follicular  odontoma  which  con- 
tained eleven  teeth  (Dr.  Weeks'  case).  Rudimentary  or  other  teeth 
have  sometimes  been  found  in  very  large  numbers;  as  many  as  several 
hundred  have  been  taken  from  the  jaws  of  one  person. 


\fl^iu 


Fig.  270. — Compound  follicular  odontoma. 


Diagnosis. — IMyxomatous  and  fibromatous  forms  of  soft  odontoma, 
both  of  which  are  formed  during  the  embryoplastic  or  odontoplastic 
periods,  are  frequently  difficult  to  differentiate  from  other  tumors 
of  the  jaw,  notably  cysts,  fibroids  and  sarcoma. 

The  diagnostic  guides  are  slow  growth,  freedom  from  pain,  irregular 
surface;  on  section,  masses  of  cement  or  dentin  may  occasionally  be 
found  to  be  encapsulated. 

Of  the  hard  forms,  dentigerous  cysts  are  usually  discovered  by  the 
yielding  of  the  thin  bulging  wall  on  pressure,  with  perhaps  a  crepitant 
sound;  puncture  to  reveal  the  character  of  the  fluid  contents,  and  on 
opening  a  tooth  is  revealed  in  cystic  enclosure. 

Radicular  odontoma,  cementome,  or  composite  odontoma  can 
usually  be  diagnosticated  with  sufficient  accuracy  to  determine  that 
the  growth  is  not  bone  by  passing  a  sharp,  light  steel  probe  through 
the  overlying  tissues  until  it  comes  in  contact  with  the  smooth,  dense, 
more  or  less  irregular  surface  of  the  tumor,  which  is  recognized  by 
sense  of  touch. 

This  much  understood  and  some  form  of  odontoma  looked  for, 
its  exact  character  may  be  determined  after  removal. 

When  doubt  exists  in  differentiation  between  soft  odontoma  and 
malignant  growths,  sections  prepared  for  the  microscope  must  be 
depended  on  for  the  final  distinction.  As  there  is  always  a  possi- 
bility of  benign  growths  assuming  malignant  form,  such  examina- 
tion should  be  made  as  a  precautionary  measure,  even  when  there 


ADULT  EPITHELIAL  TUMORS  449 

may  be  reasonable  certainty  that  no  such  comphcation  exists.  It 
is  the  author's  custom  as  a  matter  of  routine  practice  to  have  even 
bony  enlargements  in  the  vicinity  of  impacted  teeth  or  odontoma 
decalcified  and  submitted  to  microscopic  examinations,  as  well  as 
surrounding  portions  of  soft  tissue.  It  has  often  happened  in  his 
experience  that  the  former  sites  of  these  apparently  benign  conditions 
have  given  rise  to  both  sarcomatous  and  carcinomatous  gro^Nlhs. 

Differentiation  from  odontoma  and  exostosis  is  sometimes  rendered 
difficult  because  of  the  extrem.e  density  that  these  bony  formations 
acquire.  ^Actinomycosis  or  chronic  bone  diseases,  such  as  tubercu- 
losis, SA-philis,  and  other  affections  in  which  there  are  alterations  in 
the  external  form  of  bone  surfaces  with  tendency  to  bone  abscess, 
are  best  distinguished  by  bacteriological  examination  of  the  contents 
of  the  cyst  and  consideration  of  the  s^-mptomatology  of  the  suspected 
disease. 

In  the  diagnosis  of  all  forms  of  odontoma,  radiographs  are  advan- 
tageous, as  such  tumors  show  plainly  in  such  pictures,  and  the  opera- 
tion is  often  simplified  by  exact  knowledge  of  the  size  and  form  of 
the  odontoma  before  removal.  Great  care  should  be  exercised  to 
determine  with  certainty  that  any  growth  of  similar  appearance  upon 
or  in  the  jaws  is  not  an  odontoma  or  other  benign  tumor  before  radical 
excision  is  performed  for  a  supposed  malignant  neoplasm.  Such  errors 
have  not  infrequently  occurred. 

Prognosis. ^Odontomas  are  benign,  and  the  prognosis  is  generally 
favorable,  but  inflammatory  necrotic  or  malignant  processes  may 
follow  in  their  wake.  If  completely  removed,  with  thorough  extir- 
pation of  the  epithelial  and  connective-tissue  elements,  there  is  no 
tendency  to  recur.  This  is  especially  necessary  with  compound  fol- 
licular odontomas. 

Treatment. — The  treatment  of  odontoma  of  every  variety  is  com- 
plete removal  of  the  growth,  destruction  of  the  cyst  walls,  and  post- 
operative treatment  designed  to  allow  the  wound  cavity  to  fill  in  by 
granulation. 

Almost  always  these  operations  can  be  thoroughly  and  sufficiently 
performed  from  within  the  mouth,  and  this  should  be  done  whenever 
possible.  Occasionally  the  situation  of  the  growth  is  such  as  to  make 
external  incision  not  only  more  effective  but  more  direct,  and  there- 
fore much  simpler.  Dentigerous  cysts  require  the  removal  of  the 
external  wall  as  completely  as  possible,  and  the  cystic  csmty  should 
not  only  be  freed  from  its  contents,  including  the  encysted  tooth 
elements,  but  the  entire  cyst  wall  should  be  destroyed  at  every  point. 
It  is  the  author's  practice  to  accomplish  this  thoroughly  with  a  surgical 
or  dental  engine  bur,  with  which  walls,  both  bony  and  membrane 
of  the  cyst,  can  be  quickly  and  completely  removed.  The  cavity 
thus  converted  as  nearly  as  possible  into  a  saucer-shaped  form  is 
easily  packed.  It  may  be  expected  to  fill  in  by  granulation  from  the 
bottom  without  danger  of  the  external  opening,  closing  first,  as  some- 
29 


450  TUMORS 

times  happens  when  too  small  an  opening  is  made,  and  thus  causing 
a  recurrence  of  cystic  conditions. 

Papilloma  or  Wart  Tumor. — This  form  of  growth,  formed  from 
cutaneous  and  mucous  papillae,  consists  of  a  fibrous  stroma  or  stem 
containing  bloodvessels  and  lymphatics  covered  by  an  epithelial 
investment. 

Etiology. — Chronic  irritation  with  a  low-grade  inflammatory  pro- 
cess as  generally  accepted  is  the  most  common  cause.  Irritating 
discharges,  as  from  diseased  conditions  and  especially  from  genital 
and  anal  borders,  are  also  etiological  factors.  In  the  mouth,  rough 
or  sharply  projecting  tooth  borders,  ill-fitting  crowns  and  bridges 
imperfect  interproximate  spaces  due  to  carious  cavities  or  ill-fitted 
fillings,  or  artificial  dentures  and  similar  conditions  leading  to  local 
irritation,  may  cause  papillomatous  growths.  In  addition  to  all  of 
the  recognized  forms  of  irritation  which  cause  papillomas  there  appears 
to  be  some  other  not  understood  reason  for  their  spontaneous  appear- 
ance without  recognizable  external  causes. 

Varieties. — (1)  Skin  warts,  (2)  Villous  warts.  (3)  Intracystic 
warts. 

Skin  Warts. — Skin  warts  are  overgrown  papillae  wdth  the  epithe- 
lium passing  from  one  papilla  to  another  in  unbroken  line  without 
invading  the  fibrous  framework.  They  may  be  single  or  multiple, 
vary  in  color  by  becoming  mottled  with  black  pigment,  attain  great 
size,  and  become  cystic. 

Symptoms. — Papillomas  have  a  structure  of  connective  tissue  with 
an  epithelial  covering  which  passes  from  one  papilla  to  another  in  an 
unbroken  line  without  invading  the  fibrous  framework,  and  this  has 
led  to  some  confusion  in  classification. 

They  present  the  appearance  of  ordinary  warts,  and  may  be  single 
or  multiple.  They  are  usually  sessile,  but  may  assume  a  cauliflower 
appearance.  They  are  of  variable  size,  occasionally  very  large,  and  of 
different  color  through  pigmentation,  and  may  become  cystic. 

Soft  Warts. — The  papillomas  that  form  upon  mucous  membrane 
usually  have  a  cauliflower  appearance.  About  the  genitalia  they 
sometimes  become  exceedingly  prolific,  and  are  called  mulberry 
growths. 

Villous  Papilloma. — ^\''illous  warts  are  usually  found  in  the  blad- 
der, pelvis  of  the  kidney,  and  similar  situations. 

Symptoms. — They  appear  in  the  form  of  long  feathery  tufts,  have 
a  connective-tissue  core,  which  is  filled  wdth  bloodvessels,  and  are 
covered  by  epithelium. 

They  may  be  single,  multiple,  sessile,  or  pedunculated.  Serious 
hemorrhage  and  even  death  has  been  known  to  result  from  rupture 
or  detachment  of  a  villous  papilloma. 

Intracystic  Villous  Papilloma.- — Intracystic  warts  occur  within 
cysts  lined  with  epithelium  in  glands  such  as  the  mammary,  ovary 
and  thyroid. 


PLATE  XI 


Papilloma  of  the  Tongue. 


Papillonia  of  the  Gum. 


PLATE    XII 


Photographic  Reproduction  of  Papilloma.     Low  Power.     (Gaylord.) 


ADULT  EPITHELIAL  TUMORS  451 

Cutaneous  Horns. — These  are  epithelial  growths  and,  according 
to  Sutton's  classification,  are  met  with  in  four  varieties: 

1.  Sebaceous  horns  are  formed  by  the  contents  of  sebaceous  cysts 
exposed  to  the  air  by  rupture  or  disease  and  dried  ^\■ith  progressive 
extension  of  the  growth  as  the  process  is  continued. 

2.  Warty  horns  which  grow  from  warts  instead  of  sebaceous  glands. 
These  growths  usually  occur  about  the  head  or  face,  and  are  much 
more  common  in  the  lower  animals  than  in  man. 

3.  Horns  growing  from  cicatrices,  extensive  growths,  from  the 
cicatrices  of  burns  have  been  reported. 

4.  Wart  horns  are  overgrown  nails  upon  the  fingers  and  toes  of 
indi\'iduals  who  from  any  cause  have  become  incapacitated  and 
unable  to  use  the  parts. 

Symptoms. — Rare  and  somewhat  famous  cases  of  horns  of  unusual 
length  have  been  reported  and  illustrated  in  many  text-books,  show- 
ing growth  of  t^^■elve  or  more  inches,  and  nails  of  unusual  length. 
Interesting  as  these  may  be,  the  really  important  aspect  of  this  sub- 
ject for  our  present  purpose  lies  in  the  papillomas  so  frequently  found 
in  the  buccal  cavity  which  require  careful  differentiation  from  malig- 
nant growths. 

Sjrmptoms  of  Papillomas  of  the  Mouth. — These  growths  are  fre- 
quently found  upon  the  dorsiun  of  the  tongue,  the  buccal  sm-faces 
of  the  cheeks,  the  gums,  particularh'  in  the  vicinity  of  ill-closing, 
interproximate  spaces,  and  the  soft  palate.  They  may  be  small  or 
increase  until  their  size  becomes  a  matter  of  serious  inconvenience. 
The  cauliflower  form  may  or  may  not  be  evident.  The  color  is  red, 
pink,  or  grayish.  The  growth  is  usually  quite  firm,  and  sometimes 
might  be  termed  hard  when  covered  bv  squamous  epithelium  ^Plates 
XI  and  XII). 

Prognosis. — Papillomas  are  benign  growths,  and  once  completely 
removed  show  no  tendency  to  recur.  The  danger,  as  has  already 
been  indicated,  lies  in  their  occasional  tendency  to  become  trans- 
formed into  sarcomas  and,  particularly  ^^■hen  occurring  upon  the 
tongue,  into  cancer.  When  growths  occur  in  the  latter  and  the 
urethral  orifice,  rupture  of  the  delicate  connective-tissue  matrix 
causes  serious  or  fatal  hemorrhage. 

Treatment. — Complete  extirpation  is  the  only  trustworthy  remedy. 
The  growth  should  be  removed  down  to  and  including  the  periosteum, 
and  in  order  to  be  safe,  tissue  should  be  excised  a  little  beyond  the 
line  of  demarcation  of  the  growth  at  all  points. 

The  possibility  of  development  of  malignant  characteristics  in 
these  growths  should  be  borne  in  mind,  and  the  microscope  depended 
upon  to  make  the  final  diagnosis  of  a  benign  condition,  or  the  revei^se. 

Figs.  271  and  272  are  examples  of  many  cases  in  the  author's  prac- 
tice, all  of  which  were  difficult  to  distinguish  from  sarcoma  until  the 
verdict  of  the  microscope  settled  the  question.  Subsequent  history 
has  confirmed  the  findings. 


452 


TUMORS 


Adenoma. — This  form  of  tumor  is  constructed  upon  the  type  of  a 
gland  without  poMer  to  produce  the  secretion  ])eculi;ir  to  the  gland 
tissue  or  type  from  which  it  springs,  and  it  has  no  ducts  that  com- 


FlG.   271.— Pal . 


if  the  glim. 


Fig.  272. — Papilloma  of  the  gum. 


ADULT  EPITHELIAL  TUMORS 


453 


municate  with  the  normal  gland.  They  are  benign,  but  contain 
both  connective  tissue  and  epithelial  cells,  which  renders  transforma- 
tion into  sarcoma  and  carcinoma  not  only  possible  but  extremely 
likely.  They  may  develop  in  any  glandular  structure,  and  may 
contain  any  glandular  tissue. 

Classification. — The  two  principal  varieties  are : 

1.  Acinous  Adenoma. — ^These  are  tumors  having  acini  lined  with 
small  epithelial  cells.  The  acini  communicate  with  each  other,  are 
grouped  together,  and  separated  by  a  connective-tissue  matrix  con- 
taining bloodvessels.  This  form  is  exceedingly  rare,  but  fibro-adeno- 
mas  are  quite  common. 


Fig.  273. — Unusual  epithelial  tumor  of  the  palate.     (After  New.) 


2.  Tubular  Adenoma. — This  form  is  quite  commonly  found  in 
mucous  membranes  possessing  tubular  glands.  It  is  soft,  slightly 
translucent,  and  somewhat  vascular,  and  exceedingly  likely  to  become 
malignant. 

The  chief  species  are  mammary,  sebaceous,  thyroid,  prostatic, 
parotid,  hepatic,  renal,  ovarian,  testicular,  gastric.  Fallopian,  and 
uterine. 


454 


TUMORS 


Etiology. — Their  origin  is  believed  to  he  due  to  some  quiescent 
congenitally  displaced  rudiment.  Irritation  doubtless  plays  some 
part  in  the  causation  of  these  as  with  other  tumors. 

Symptoms.- — Adenomas  of  the  mucous  membrane  of  the  mouth 
usually  occur  upon  the  lower  lip  and  cheeks  in  the  form  of  smooth, 
firm,  nodular  enlargements  beneath  the  mucous  membrane,  but 
slightly  adherent.  They  are  usually  encapsulated,  are  not  painful, 
grow  slo\\'ly,  and  except  in  rare  instances  give  slight  inconvenience, 
unless  when  in  the  course  of  years  they  attain  unusual  size,  or  ulcerate 


'•:2Q^& 


*  ^W  Ek-    W^>    ■  -■^^•^.    i^S^c-''  '/'   :,'<■' vr  c 


Fig.  274  (same  as  FIk.  273). — Areas  showing  the  cells'  nests.    In  other  areas  the  central 
part  of  the  nests  has  dropped  out,  leaving  the  outer  layer  of  cells.    (After  New.) 

or  assume  malignant  character.  Occurring  as  they  sometimes  do 
upon  the  soft  palate,  the  sound  of  voice  or  breathing  may  be  more  or 
less  afl'ected.  Such  tumors  may  attain  the  size  of  a  hen's  egg.  They 
are  occasionally  found  at  the  base  of  the  tongue  or  near  the  foramen 
cecum.  These,  as  reported  by  Wolff,  Chamisso  de  Boncourt,  Benja- 
min, Watson,  Tewels,  and  others,  were  all  discovered  in  young  women. 
They  were  invariably  situated  in  the  median  line,  with  a  smooth, 
slightly  notched  surface,  elastic,  and  with  vascularity  well  marked.^ 

1  Von  Bergmann:  System  of  Practical  Surgery,  i,  859. 


ADULT  EPITHELIAL  TUMORS 


455 


They  have  been  found  to  contain  thyroid  tissues,  and  ha\e  been  termed 
acccssury  thyroid  tumors. 

Differential  Diagnosis. — Adenomas  must  be  differentiated  from  gland- 
ular enlargements,  which  are  simply  an  increase  of  natural  glandular 
elements,  from  retention  cysts,  and  inflammatory  conditions.  The 
distinction  betA\'een  adenoma  and  carcinoma  is  often  very  slight. 

"As  soon  as  the  epithelial  cells  lose  their  regularity  of  disposition 
and  collect  in  groups,  or  make  their  way  outside  of  the  acini  into  the 
tissues,  then  the  change  from  the  benign  to  the  malignant  tumor  has 
begun,  and  the  entire  clinical  aspect  of  the  case  is  altered.  This  change 
may  be  the  result  of  external  irritation,  of  such  tissue  changes  as  preg- 
nancy and  lactation,  or  of  the  undivided  changes  which  advancing 
years  seem  to  produce."^ 


Fig.  275. — Adenoma  of  the  palate  of  a  young  woman.  There  was  no  recurrence 
after  its  complete  surgical  removal,  which  was  accomplished  without  entering  the  nasal 
cavity. 

Prognosis. — ^Yith  true  adenoma  the  prognosis  is  favorable  and  there 
is  little  if  any  likelihood  of  recurrence. 

Treatment. — The  extirpation  of  the  growth  is  usually  effected  through 
the  mouth.  At  the  base  of  the  tongue  under  unusual  conditions  some 
of  the  operations  described  (pages  537  and  539)  for  removal  of  growths 
in  that  region  may  be  required. 

Neuroma. — A  neuroma  is  a  tumor  consisting  almost  entirely  of 
nerve  tissue. 

Varieties. — ^The  term,  used  in  a  strict  sense,  applies  to  a  very  rare 
form  of  tumor,  but  as  commonly  applied  includes  tumors  containing 
nerve  elements  and  fibrous  tissue.    These  are  more  properly  termed 


Park,  Modern  Surgery,  p.  284. 


456 


TUMORS 


false  neuromas.     Plexiform  neuromas  appear  in  the  form  of  nodules 
along  the  course  of  the  nerve  or  in  a  nerve  plexus  (Fig.  270.) 


Fig.  270. — Plexiform  neuroma,  dissected  free  from  all  adherent  tissues.     (Lexer.) 


f'lG.  277. — Multiple  neuroma.  Nerves  of  the  arm,  the  lumbar  plexus,  and  the  sciatic  nerve. 
Specimen  from  the  Museum  of  the  College  of  Physicians  and  Surgeons.     (Starr.) 


ADULT  CONNECTIVE-TISSUE  TUMORS  457 

Ganglionic  neuro7nas  are  tumors  composed  of  or  containing  ganglion 
cells.  Myelijiic  neuromas  contain  newly  developed  medullated  fibers. 
Amyelinic  neuromas  are  formed  of  non-medullated  nerve  fibers.  These 
belong  to  the  false  neuromata  because  the  new  tissue  is  fibrous. 

Etiology.— The  causes  of  neuromas  are  injuries  to  the  nerves,  such 
as  amputation,  which  leads  to  amimtation  neuromas  or  bulbous  masses 
at  the  cut  ends  of  nerves.  Heredity  is  supposed  to  be  accountable  for 
the  multiple  fibromas  of  superior  superficial  nerves. 

Symptoms. — Both  the  cranial  and  spinal  nerves  are  subject  to  this 
affection.  Park  believes  the  sensory  nerves  are  more  likely  to  become 
attacked  than  the  motor.  The  nerve  least  often  attacked  is  the  optic. 
The  fifth  nerve,  through  operations  for  neuralgia  and  by  reason  of 
exposure  to  injury  at  various  points,  is  subject  to  nerve  tumor.  Pain, 
loss  of  sensation,  paralysis,  or  muscular  spasm  may  be  objective  symp- 
toms according  to  the  nerve  or  nerve  branch  that  may  be  involved 
(Fig.  277). 

Prognosis. — Neuromas  are  benign  growths,  but  many  of  them  are 
sarcomatous  from  the  beginning,  and  in  others  malignancy  is  developed 
as  the  growth  proceeds.  The  result  of  treatment  will,  of  course,  be 
dependent  upon  the  situation  of  the  tumor  and  the  nerve  affected  and 
the  character  of  both. 

Treatment. — Excision  is  the  only  remedy  when  the  exact  location 
of  the  tumor  can  be  determined,  providing  its  situation  is  such  as  to 
make  operation  possible.  The  paralysis  following  operation  upon  the 
nerve  trunk  may  sometimes  be  overcome  by  nerve  suture,  grafting, 
and  similar  treatment. 

Glioma. — Gliomas  are  tumors  derived  from  the  sustaining  tissue 
of  the  central  ners'ous  system  (the  neuroglia)  and  composed  of  glia 
cells,  more  or  less  closely  maintaining  the  normal  elements.  The  sites 
of  these  tumors  are  the  brain  and  cord,  optic  nerve  and  retina,  olfactory 
lobe.  They  therefore  do  not  require  description  among  the  tumors  of 
the  mouth. 

ADULT  CONNECTIVE-TISSUE  TUMORS. 

Lipoma  or  Fatty  Tumor. — Etiology. — Heredity  seems  to  have  a 
marked  influence.  jMultiple  lipomas  have  been  known  in  families, 
and  inherited  tendency  has  been  transmitted  through  several  genera- 
tions.   In  some  cases  the  tumor  is  congenital. 

Varieties.^ — ^The  principal  varieties  are:  Encapsulated,  enclosed  in 
an  exceedlingly  thin  capsule,  and  diffuse,  when  the  margins  are  not 
clearly  defined. 

Symptoms.— These  growths  are  rarely  found  in  the  mouth.  Knack, 
upon  a  study  of  the  hterature,  collected  reports  of  29  cases  of  lipoma 
in  the  oral  cavity,  12  on  the  tongue,  9  on  the  floor  of  the  mouth,  7  on 
the  lips,  and  1  on  the  gums  and  soft  palate.^ 

1  Von  Bergmann:  System  of  Practical  Surgery,  i,  156. 


458 


TUMORS 


"In  the  mouth  these  growths  are  usually  under  the  mucous  mem- 
brane of  the  floor  of  the  mouth  and  originate  deep  within  the  muscular 
layers.  The  overlying  mucous  membrane  is  not  adherent,  and  the  light 
yellow  color  of  the  lipoma  can  be  indistinctly  seen  through  the  altered 
mucous  covering. 

"  Lipomata  of  the  cheek  are  situated  in  the  submucous  layer  and 
easily  distinguished  from  large  lipomata  of  the  skin." 

Prognosis. — They  are  benign  and  do  not  recur  unless  of  mixed  nature. 

Treatment. — Tliis  consists  in  complete  extirpation. 

Chondroma  (Enchondroma,  Enchondrosis,  Chondroid,  Chondroid 
Exostosis). — This  tumor  is  composed  largely  or  entirely  of  cartilage. 


Fig.  278. — Gum  tissue  from  the  region  of  an  impacted  lower  third  molar,  showing 

cartilage  formation. 


Etiology. — ^Congenital  tendency  appears  to  be  hereditary  in  some 
cases.  Irritation  as  a  causal  factor  is  indicated  by  formation  of  car- 
tilage in  the  tendons  of  muscles  subject  to  frequent  irritation  and 
traumatism  by  outgrowths  of  cartilage  from  bones  that  have  been 
injured  or  fractured.  According  to  Virchow/  chondromas  often  spring 
from  remnants  or  islands  of  cartilage  left  in  abnormal  situations. 

Varieties. — i\)  T'artilaginous  outgrowths,  ecchondrosis  or  ecchon- 
dromas.  (2)  Cartilaginous  tumors  or  true  chondromas  which  originate 
in  non-cartilaginous  structures. 

Symptoms. — The  tumors  occur  most  frequently  on  the  metacarpal 
bones  and  phalanges  of  the  hands,  less  frequently  in  other  long  bones, 

1  Stengel:  Text-book  of  Pathology,  p.  154. 


ADULT  CONNECTIVE-TISSUE  TUMORS 


459 


and  somewhat  rarely  upon  bones  of  the  face.  They  are  not  infrequently 
found  in  soft  ])arts,  as  the  tendons  of  muscles,  salivary  glands,  tonsils, 
and  other  glands  of  the  body.  In  rare  instances  metastases  have  been 
known  to  occur  in  the  lungs,  spleen,  brain,  liver,  and  heart  as  reported 
by  ]\tichacloff^  who  collected  14  such  cases. 

Prognosis. — The  prognosis  is  good.  The  tumor  is  benign,  grows 
slowly,  does  not  recur  after  removal,  and  has  almost  no  tendency  to 
metastasis;  mixed  forms  of  cartilaginous  tumor  which  are  quite  common 
may  present  a  more  serious  aspect.  P'ig.  278  is  an  illustration  of  gum 
tissue  in  the  region  of  the  third  molar  tooth  that  shows  the  beginning 
of  such  a  growth. 

Treatment. — Surgical  removal  is  indicated  whenever  the  situation  or 
threatening  aspect  of  the  tumor  requires  such  treatment. 


Fig.  279. — Osteoma  of  the  lower  jaw. 


Osteoma. — Osteoma  is  a  tumor  composed  of  bony  tissue. 

Etiology. — Unusual  stimulation  of  the  periosteum  by  irritation, 
traumatic  injury,  or  diseased  conditions  are  among  the  causes. 

Varieties. — Exostosis,  growth  from  the  external  surfaces  of  the  bone. 
Enostosis,  growth  from  the  internal  structure  of  the  bone.  These  may 
be  ebiirnated,  or  very  hard,  compact,  or  similar  to  compact  bone  struc- 
ture, and  ca7icellous  or  spongy. 

Symptoms. — They  are  most  commonly  found  in  connection  with  the 
periosteum  of  bone,  medulla  or  cartilage,  but  also  occur  in  soft  parts 
of  the  body,  as  in  the  brain  structures,  diaphragm,  coat  of  the  eye,  air 

1  Coplin:  Manual  of  Pathology,  p.  340;  Quotation  from  Patel:  Rev.  Chir.,  March  10, 
1904,  p.  398. 


460  TUMORS 

passages,  lymph  nodes,  nerve  centers,  and  tendons.^  These  may  give 
much  or  little  trouble,  according  to  their  situation,  may  grow  into  the 
interior  of  the  skull,  the  frontal  or  other  sinus,  the  cavity  of  the  orbit 
or  the  nose.  In  such  situations  they  may  give  rise  to  disturbance; 
otherwise  they  are  painless  and  grow  slowly.  They  sometimes  lead  to 
inflammatory  conditions  resulting  in  necrosis  and  more  or  less  extensive 
loss  of  bone  structure. 

Prognosis. — The  prognosis  is  good,  although  the  question  of  recur- 
rence is  necessarily  dependent  upon  correction  of  the  exciting  cause, 
as  well  as  removal  of  the  growth.  Occasionally  such  tumors  become 
carcinomatous. 

Treatment. — Treatment  consists  in  removal.  Complete  excision  of 
the  affected  bone.  Fig.  279  shows  a  section  of  an  osteoma  of  the 
lower  jaw  in  a  woman,  aged  forty-nine  years,  excited  by  an  impacted 
unerupted  tooth. 

Fibroma. — Fibromas  are  tumors  composed  of  wavy  bundles  of  fibrous 
tissue. 

Etiology. — The  causes  of  fibroma,  as  of  other  tumors,  are  more  or 
less  enshrouded  in  mystery,  but  clinically  the  influence  of  irritations 
is  an  important  factor.  This  is  shown  by  the  frequent  development 
of  fibromas  in  old  scars  or  situations  that  have  been  exposed  to  injury 
or  chronic  irritation. 

Symptoms. — Fibroma  may  be  hard  or  soft  and  occurs  in  many 
different  situations  and  structures  of  the  body,  but  most  commonly 
in  the  ovary,  uterus,  the  intestines,  the  gums,  nerve  sheaths,  and  skin. 
Hard  fibroma  is  usually  oval  and  globular,  smooth,  movable,  and  pain- 
less, unless  attached  to  a  nerve.  The  soft  fibroma  is  very  similar 
except  that  it  is  more  yielding  and  elastic.  Pure  fibroma  is  somewhat 
rare.  Most  fibromas  are  in  combination  with  other  tissues.  Simple 
fibroma  of  the  skin  presents  a  nodule  about  the  size  of  a  pea,  is  of  firm 
consistence  and  situated  loosely  in  the  tissue  immediately  under  the 
integument.    These  are  exceedingly  painful. 

Neurofibromatosis  is  a  rare  condition  in  which  there  is  overgrowth 
of  fibrous  tissue  in  connection  with  nerves.  True  keloid  is  most  common 
in  the  negro,  and  is  composed  of  bundles  of  coarse  fibers  in  the  chorium, 
the  papillae  and  epidermis  being  intact. 

Cicatricial  keloid  develops  in  the  substance  of  a  scar,  and  is  not 
covered  by  the  papular  layer.  It  is  the  bete  noir  of  surgeons,  as  it  occurs 
in  the  scars  of  sutures  and  wounds  that  in  the  beginning  may  have 
been  very  slightly  noticeable  and  shows  a  tendency  to  recur  after  it  has 
been  removed  (Fig.  280). 

Prognosis. — The  prognosis  is  good.  They  do  not  recur  after  removal, 
do  not  give  rise  to  metastasis,  and  unless  in  combination  with  malig- 
nant growths  are  not  dangerous  except  through  pressure  upon  the  vital 
parts  or  interference  with  the  function  of  important  organs, 

1  Coplin:  Manual  of  Pathology,  p.  341. 


ADULT  CONNECTIVE-TISSUE  TUMORS 


461 


Treatment.— Surgical  removal  is  being  generally  supplanted  by  .T-ray 
or  radium  treatment,  which  in  cases  such  as  those  illustrated  in  Figs. 
281  and  282  will  insure  a  better  result  without  fear  of  creating  notice- 
able deformity. 


Fig.  280. — Keloid.     (Hardaway.) 

Myoma. — Myomas  are  tumors  composed  of  muscle  tissue;  strictly 
speaking,  a  leiomyoma  or  myoma  levi  cellulare,  or  when  composed  of 
non-striated  muscle  fiber,  because  many  modern  writers  discourage 
the  use  of  the  term  "  rhabdomyoma,"  used  to  describe  tumors  of  striped 
muscle  fiber,  because  this  exceedingly  rare  form,  usually  found  in  the 
kidney  and  the  uterus,  is  seldom  or  never  a  true  myoma. 


462 


TUMORS 


Etiology. — As  with  other  tumors,  there  is  indication  in  .-,ome  of  mis- 
placed embryonic  elements,  and  in  others  irritants  appear  to  have  an 
undoubted  part  in  causation. 

Symptoms.^They  are  commonly  found  in  the  gastro-intestinal 
tract,  uterus,  and  skin,  and  according  to  Coplin  are  also  found  more 
or  less  frequently  in  the  tongue.  They  may  be  very  small  nodules 
or  of  enormous  size,  weighing  60  to  70  pounds.  Williams  reports  one 
removed  by  severance  weighing  195  pounds.  They  may  be  single  or 
multiple,  and  when  arising  from  submucous  or  subserous  tissue  may 
be  polypoid  and  hang  by  a  small  pedicle.  They  are  surrounded  by  a 
capsule  and  quite  hard  unless  altered  by  secondary  degenerations, 
which  may  be  cystic  or  calcific,  with  corresponding  alteration  in  the 
character  and  growth. 


Fig.  281. — Xcjrro  with  keloid  on  both 
cheeks.  (Surgical  Clinic  of  the  Southern 
Dental  College,  Atlanta,  Ga.) 


Fig.  2^'J..  m  u-  \  i.-'.v  of  negro,  sliowing 
keloids  on  cheek  and  neck.  (Surgical 
Clinic  of  the  Southern  Dental  College, 
Atlanta,  Ga.) 


Prognosis. — They  are  benign  and  grow  slow  ly.  Their  only  dangerous 
features  occur  through  interference  with  other  parts  by  reason  of  their 
enormous  size  and  the  pressure  sometimes  occasioned,  and  through 
degenerative  changes,  to  wh'ch  they  are  quite  subject. 

Treatment. — The  treatment  consists  in  surgical  extirpation. 

Angioma. — Angiomas  are  tumors  composed  of  bloodvessels.  Coplin 
uses  the  term  angioma,  and  includes  both  blood-  and  l}'mph-\essel 
tumors,  distinguishing  the  bloodvessel  tumors  by  the  term  hemangioma. 

Classification. — 1.  CajnUary  Angiovui  (Xevus,  Port-wine  ]\Iarks, 
Telangiectasis). — It  is  usually  congenital.  They  appear  upon  the 
skin  and  subcutaneous  tissue  in  all  parts  of  the  body,  on  the  surface 


ADULT  CONNECTIVE-TISSUE  TUMORS 


463 


and  the  su})mucoiis  surface  of  the  tongue,  inside  of  the  mouth,  con- 
junctiva, and  in  similar  situations.  Sometimes  they  spread  over  a 
relati\'ely  large  area. 


Fig.  283.- 


-Angioma  of  the  lip. 
land.) 


(Westmore- 


FiG.  284. — Same  boy  shown  in 
Fig.  283  after  operation.  (West- 
moreland.) 


2.  Cavernous  angiomas  are  sometimes  called  erectile  tumors.  They 
are  occasionally  found  in  the  tongue,  voluntary  muscles,  larynx,  and 
thjToid,  but  chiefly  upon  the  skin,  and  are  exaggerated  forms  of  capil- 
lary angioma  (Fig.  285). 


Fig.  285. — Angioma  of  the  gum  and  palate.     (Campbell.) 


3.  Arterial  or  Plexiform  Angiomas. — In  these  arteries  of  unusual 
number  and  character  occur  in  the  scalp,  occasionally  the  perineum, 
but  rarely  in  other  parts  of  the  bod}'. 

Diagnosis. — The  diagnosis  of  angioma  is,  as  a  rule,  quite  simple. 
The  discoloration  of  the  skin,  recession  of  blood  upon  pressure  and 
murmur  usually  make  recognition  quite  plain.  In  the  mouth,  however, 
these  tumors  are  not  always  easily  differentiated.    The  author  has  had 


464 


TUMORS 


many  cases  like  the  tumor  from  an  edentulous  portion  of  the  alveolar 
ridge  of  the  lower  jaw  of  a  woman  of  middle  age.  Its  appearance  was 
not  unlike  other  tumors  found  in  similar  situations.  The  history  of 
repeated  removal  and  recurrence  confused  the  diagnosis  until  cleared 
up  by  the  microscope. 

Prognosis.— The  prognosis  is  good.  They  are  benign,  but  frequently 
become  the  seat  of  malignancy. 

Treatment. — Surgical  remo^'al  when  the  vessels  are  much  dilated 
must  not  only  include  a  careful  dissection  of  the  tumor,  but  ligation 
of  the  deeper  vessels  of  supply  to  prevent  recurrence  and  to  check 
immediate  hemorrhage. 

The  smaller  forms  may  be  successfully  treated  with  the  electric 
needle,  depending  upon  coagulation  of  the  blood,  organization  of  a 
thrombus,  and  formation  of  cicatricial  tissue  as  a  result  of  the  effect 
of  the  electric  current.  Within  the  mouth,  it  is  the  author's  belief 
that  the  most  effective  way  in  many  cases  is  by  the  use  of  the  actual 
cautery.  The  ligation  of  vessels  supplying  the  part  for  the  purpose  of 
cutting  off  the  blood  supply  and  causing  gradual  reduction  of  the 
tumor  is  not  so  often  em])loyed  at  the  present  time  as  formerly.  The 
disfiguring  effect  of  nevi  upon  the  face  is  sometimes  overcome  by 
removal  by  careful  dissection  of  the  affected  skin  surface  and  the 

grafting  of  new  skin  upon  the  denuded 
area.  More  recently  the  a:-rays  have 
been  used  with  reported  good  results 
in  some  cases,  also  the  actinic  rays 
of  the  Finsen  lamp.  The  latest  en- 
couragement, however,  comes  from  the 
use  of  liquid  air  and  carbon  dioxide 
snow. 

Lymphangioma. — L\Tnphangioma  is  a 
tumor  composed  of  dilated  l\Tnph  ves- 
sels or  l\nnph  spaces. 

Classification. — There  seems  to  be 
some  confusion  among  authors  with 
regard  to  the  distinction  in  classifica- 
tion of  the  varieties  of  hmph  tumor.  It 
is  sufficient  for  our  present  purpose, 
howe\'er,  to  recognize  the  following 
principal  forms: 

Elephantiasis     concjenita    mollis,     in 
which    the    subcutaneous    tissues    are 
edematous  and  may  contain  distinct  cystic  formations,  as  in  congenital 
enlargement  of  the  tongue. 

Congeniial  cystic  hygroma  is  a  cystic  formation  of  the  lymph  spaces. 
Macroglossia  or  lymphangioma  of  the  tongue.    Sometimes  the  tongue 
is  so  large  as  to  protrude  from  the  mouth,  as  shown  in  Figs.  286  and 
335,  p.  541. 


Ftg.  286. — Macroglossia. 
(Westmoreland.) 


ADULT  CONNECTIVE-TISSUE  TUMORS 


465 


Macrocheilia  is  the  same  affection  of  the  hp  as  shown  in  Figs.  368 
and  o69,  i)p.  573  and  574. 

Nevtis  lyniphuticus,  small,  closely  aggregated,  deep-seated,  trans- 
parent vesicles  varying  from  a  })inpoint  to  that  of  a  hemp  seed.  When 
picked,  lymi)h  or  blood-stained  lymph  flows  from  them. 


Fig.  287. — Lymphangioma  of  tongiie.  Girl,  aged  twelve  years,  treated  at  the  Mayo 
Cliiiic  and  reported  by  Dr.  Gordon  B.  New.  She  was  treated  with  radium  for  two  hours 
daily  with  the  22-mg.  tube,  with  no  screening,  for  a  period  of  twelve  days.  Previous 
x-ray  treatments  had  made  no  improvement. 

Symptoms. — The  symptoms  consist  in  congenital  enlargement  of 
certain  parts  which  appears  to  be  entirely  due  to  abnormal  develop- 
ment of  lymph  spaces. 


Fig.  288. — Tongue  of  same  girl  shown  in  Fig.  287  after  treatment. 

Treatment. — Surgical  removal  when  necessary  is  indicated.  In  case 
of  the  tongue  it  is  advisable  to  remove  a  portion,  and  if  possible  to 
preserve  the  organ  in  such  form  as  to  enable  it  to  fit  properly  within 
the  mouth. 

Gordon  B.  New,  of  the  Mayo  Clinic,  reports  the  successful  treat- 
ment of  lymphangioma  of- the  tongue  with  radium.  He  prefers  radium 
treatment  to  surgical  measures,  because  excision  of  the  tongue  tissue 
is  so  likely  to  leave  that  organ  stiff  and  board-like  from  scar  formation. 
(See  Figs._287-290.) 
30 


4G6 


TUMORS 


Macroclieilia  requires  exceedingly  careful  operative  treatment  to 
remove  the  unusual  thickness  of  the  lip  and  yet  preserve  the  cosmetic 
effect  of  the  border  of  the  prolabiiun  without  stiffening  the  lip  or  alter- 
ing its  appearance  during  speech  and  laughter. 

Lymphoma. — Lymphoma  is  a  tumor  of  the  lymph  node.  This  term 
is  applied  to  the  glandular  enlargements  of  tuberculosis,  syphilis,  and 
other  infectious  diseases.  They  are  usually  apparent  in  the  lymph 
nodes  of  the  neck,  groin,  and  maxilla.  The  character  of  the  disease  is, 
as  a  rule,  indicated  by  such  terms  as  s\'philitic  lymphoma,  tuberculous 
•lymphoma,  etc. 

Treatment. — Treatment  is  that  of  the  local  treatment  of  an  inflam- 
matory process  and  that  of  the  disease  by  which  it  is  caused. 


Fig.  289. — Lymphangioma  of  the 
tongue  of  a  boy,  aged  two  and  a  half 
years,  treated  at  the  Mayo  CUnic  and 
reported  by  Dr.  Gordon  B.  New.  He  was 
treated  two  hours  daily  with  a  28-mg. 
tube  of  radium,  unscreened,  for  a  period 
of  ten  days. 


Fi( 


200. — Same   boy  shown  in  Fig 
289  after  treatment. 


Lymphadenoma    (Hodgkin's    Disease,    Pseudoleukemia). — Ljth- 

phadenoma  is  a  malignant  newgrowth. 

Etiology. — It  was  generally  accepted  as  being  sarcomatous,  although 
there  were  many  reasons  for  assuming  that  it  is  sometimes  of  tuber- 
cular origin  until  Bunting  and  Yates  disco^'ered  the  B.  hodgkini  as 
described  on  p.  428. 

Symptoms. — In  the  beginning,  painless  enlargement  of  the  lymph 
nodes  of  the  neck  occurs.  These  at  first  are  freely  movable  and  without 
tendency  to  suppm'ation  or  degeneration.  Later  it  extends  to  glands 
in  other  regions.  The  nodes  become  fused  into  irregular  masses  some- 
times of  large  size  and  cause  disfigurement.  There  is  enlargement  of 
the  spleen,  anemia,  progressive  anemia,  and  death. 

Diagnosis. — Its  diagnostic  importance  lies  in  the  necessity  for  differ- 
entiation from  other  affections  of  the  glands  in  the  region  of  and  sur- 
rounding the  buccal  cavity  (see  p.  428,  and  Figs.  254  and  255). 

Prognosis. — Death  usually  results. 


ADULT  CONNECTIVE-TISSUE  TUMORS 


467 


Treatment. — Treatment  is  unsatisfactory.  Arsenic  in  early  stages, 
removal  of  the  individual  glands,  and  the  use  of  the  a'-rays.  They  are 
all  recommended. 


Fig.  291. — Face  of  young  woman  in  whose  case  nearly  all  of  the  lower  jaw  was  removed 
from  the  ramus  on  the  left  side  to  the  molar  region  on  the  right  for  the  removal  of  the 
myxoma  shown  in  Fig.  292.  Preservation  of  the  periosteum  which  was  permitted  on 
account  of  the  character  of  the  growth  and  retention  of  the  form  of  the  jaw  during  healing 
process  restilting  in  new  bone  formation  so  that  the  girl  is  now  able  to  wear  a  lower  set  of 
teeth  on  the  newly  formed  jaw  and  is  only  slightly  shorter  on  the  left  side  instead  of 
having  the  great  deformity  that  would  otherwise  have  resulted. 

Myxoma. — ^Myxoma  is  mucous  tissue  tumor. 

Etiology. — The  cause  of  myxoma  are  identical  with  those  of  fibroma, 
and  combinations  of  the  two  render  radical  distinctions  impossible. 


Fig.  292. — Same  girl  shown  in  Fig.  291  before  the  removal  of  the    myxoma,  showing 
the  extent  of  the  jaw  involved. 


Symptoms. — It  appears  as  a  homogeneous  structural  gelatinous  mass, 
grayish  or  reddish  white  in  color,  and  composed  of  a  gelatinoid  or 
whitish  mucilaginous  material.  When  arising  in  submucous  or  cuta- 
neous or  subcutaneous  tissues  they  may  be  pedunculated  and  in  the 
form  of  a  distinct  polyp.  A  pure  form  of  nasal  myxoma  occurs  in 
polyps  of  the  mucous  membrane  of  the  nasal  passages  and  accessory 
sinuses.    These  polypi  may  be  single  or  in  clusters,  and  their  effect 


468  TUMORS 

is  to  cause  nasal  obstruction  which  sometimes  leads  to  diseased 
conditions  of  the  associated  sinuses  or  the  pharynx. 

Prognosis. — Under  proper  treatment  this  is  favorable. 

Treatment. — The  treatment  consists  in  removal  and,  if  possible, 
correction  of  the  predisposing  condition,  otherwise  there  is  likeli- 
hood of  recurrence. 

In  the  case  shown  in  Figs.  291  and  292  the  myxoma  was  peeled  out 
with  the  fingers  from  the  angle  of  the  jaw  on  the  left  side  of  the  mouth 
to  the  middle  of  the  body  of  the  jaw  on  the  opposite  side.  It  was 
removed  in  large  masses,  almost  intact. 

MALIGNANT  GROWTHS. 

Sarcoma. — Sarcoma  is  an  embryonic  connective-tissue  tumor  in 
which  the  cellular  constituents  usually  predominate  over  the  inter- 
cellular substance. 

Varieties. — Varieties  of  sarcoma  placed  for  clinical  purposes  in  the 
order  of  their  malignancy  are:  (1)  Giant  cell.  (2)  Spindle  cell,  (o) 
Large  spindle  cell.  (6)  Small  spindle  cell.  (3)  Round  cell.  (4) 
Mixed   cell.      (5)  Alveolar.      (6)  Melanotic. 

Most  sarcomas  are  mixed  growths.  The  determination  of  malig- 
nancy depends  upon  the  character  of  the  cells  that  predominate  in 
the  growth,  and  it  is  usually  described  as  of  a  type  in  accordance 
with  the  predominating  cells. 

Alveolar  sarcoma  is  a  rare  form  in  which  the  cells  assume  an  alveolar 
enlargement  quite  like  carcinoma. 

Giant-cell  or  myeloid  sarcoma  is  a  form  resembling  the  red  marrow 
of  young  growing  bone. 

Sarcomatous  growths  show  marked  tendency  to  secondary  changes 
which  sometimes  result  in  the  more  or  less  complete  development  of 
connective-tissue  structures.  Thus  we  have  osteosarcoma  when  true 
bone  formation  occurs,  chondroid  or  chondrosarcoma  when  cartilage 
results,  myxosarcoma  with  mucoid  tissue,  endothelioma  (plexiform 
angiosarcoma),  a  highly  vascular  tumor  due  to  preexisting  or  newly 
formed  vessels  with  cell-nest  formed  by  proliferation  of  endothelial 
cells  (Fig.  293).  Mixed  tumors  of  the  parotid  gland  are  quite  commonly 
endotheliomas  (Fig.  294).  Melanosarcoma  is  distinguished  by  black 
pigment  in  cells  and  intercellular  substance,  and  is  generally  recognized 
as  the  most  malignant  of  all  sarcomas  (Fig.  295). 

Sarcoma  of  the  Jaw. — Epulis. — This  term  is  applied  to  tumors 
which  spring  from  the  fibrous  tissue  of  the  gum  and  the  periosteum, 
and  which  might  be  papilloma,  fibroma,  carcinoma,  or  sarcoma.  It 
is,  however,  most  commonly  used  to  describe  giant-cell  sarcoma. 

Etiology. — There  is  usually  some  local  irritation  which  appears  to 
excite  the  growth. 

Sjrmptoms. — The  growth  appears  upon  the  gum  (Plate  XIII,  Fig.  1), 
gives  little  disturbance  outside  of  mechanical  interference,  spreads 


PLATE    XIII 


Epulis.     (Grunwald. 


FIO.   2 


Woman,  Aged  Seventy    Years,    with    the  Sarcoma  froni  which 
the  Sections  Shown  in   Figs.  295,  296,  and  297  w^ere  Cut. 


470 


TUMORS 


history  of  this  case  showed  that  the  trouble  began  in  the  maxillary 
sinus  years  before.     After  the  first  removal  there  was  a  period  of  two 


Fig.   294. — Mixed  tumor  of  the  parotid.      (Sultan-Kiiss.) 


Fig.  295. — Section  of  nielanosarcoma,  showing;  pigmentation. 

years  without  recurrence.  The  sections  indicate  very  plainly  the  pre- 
dominance of  spindle  cells  in  the  older  parts  of  the  growth,  mixed 
spindle  and  round  cells  in  a  later  section,  round  cell,  and  finally  melan- 


MALIGNANT  GROWTHS 


47i 


otic  sarcoma.     Figs.  299  and  300  are  sections  of  a  growth  illustrating 
one  danger.     It  had  been  examined  at  a  well-known  laboratory  and 


Fig.  296. — Spindle-cell  sarcoma.    A  section  from  the  growth  shown  in  Fig.  294. 


Fig.  297. — ^Round-cell  sarcoma.    A  section  of  the  growth  shown  in  Fig.  294    cut  from  a 
portion  of  later  development  than  Fig.  296. 


472  TUMORS 

reported  as  inflammatory  tissue.  When  the  patient  came  under  the 
author's  care  a  section  was  made  which  seemed  to  confirm  the  pre- 
vious report,  yet  deeper  sections  made  after  removal  of  the  deeper- 
seated  portions  of  the  gro\\'th  show  plainly  the  sarcomatous  condition. 
In  another  of  the  author's  cases  microscopic  sections  failed  to 
disclose  the  malignant  character  of  a  tumor.  Under  these  circum- 
stances it  was  deemed  unwise  to  make  a  wide  resection  of  the  jaw, 
and  yet  it  was  subsequently  learned  that  this  patient  died  within 
six  months  from  sarcoma  recurring  in  the  same  region.  In  dealing 
with  malignant  tumors  of  the  jaw,  both  sarcomatous  and  carcino- 
matous, the  decision  as  to  the  character  of  the  operation  is  a  grave 


FiG.[298. — The  pigmentation  of   ]i  i    section  from   the  same  growth 

shown  in  Figs.  294,  296  and  297. 

one.  Undoubtedly  many  jaws  haAe  been  resected  and  the  future 
comfort  of  the  lives  of  these  individuals  blasted  when  the  growths 
were  benign  and  there  was  no  need  of  radical  operation.  On  the 
other  hand,  to  do  an  insufficient  operation  in  the  face  of  active  malig- 
nancy is  merely  to  add  fuel  to  the  flame  and  hasten  the  progress  of 
malignant  development  (Fig.  301).  Immediate  diagnosis  by  the 
microscopic  examination  of  a  frozen  section  at  the  time  of  the  opera- 
tion, when  this  can  be  done,  is  by  all  means  the  best  method  of  dealing 
with  such  gro^Nlhs. 

Operation  for  Giant-cell  Sarcoma. — The  gro^^•th  must  be  completely 
removed  down  to  and  including  the  periosteum,  as  well  as  the  teeth 
that  may  be  immediately  adjacent  to  the  growth.     It  is  the  author's 


MALIGNANT  GROWTHS 


473 


practice  to  remove  one  tooth  upon  each  side  beyond  the  growth  and 
with  a  surgical  or  dental  engine  bur  to  remove  the  alveolar  process 
down  to  and  including  the  full  extent  of  the  tooth  socket,  so  that  by 


Fig.  299. — Section  of  a  sarcoma  of  the  lower  jaw. 


l^'  --^v?^;^  ::.  13^ 


Fig.  300. — Section  of  a  sarcoma  of  the  lower  jaw.     Same  case  as  Fig.  299. 


474 


TUMORS 


no  possibility  might  there  be  a  portion  of  the  pericementum  allowed 
to  remain. 

The  treatment  of  other  more  malignant  forms  of  sarcoma  is  described 
with  carcinoma  under  Treatment  of  ^Malignant  Growths. 


Fig.  .301. — Sarcoma.     (Westmoreland.) 


CARCINOMA— CANCER. 

Carcinoma  is  an  embryonic  or  atypical  neoplasm  that  always 
de\elops  from  epithelial  cells. 

Varieties. — (1;  Epithelial  carcinoma  or  epithehoma.  (2)  Glandular 
carcinoma. 

1.  Epithelionca. — There  are  three  principal  txpes  of  epithelioma — 
squavicnis,  cylindric-cell  and  tabulated. 

Squamous  EPITHELIO^L\. — ^This  form  grows  upon  cutaneous  or 
mucous  surfaces,  and  its  epithelial  elements  are  much  like  the  squa- 
mous epithelium  of  skin  and  mucous  membrane.  Transverse  sections 
show  topical  nesting  of  cells,  called  epithelial  nests.  \Vhen  these 
harden,  as  by  age  and  keratinization,  they  are  termed  pearls,  and  it 
is  called  a  pearly  epithelioma  CFigs.  302  and  30.3). 

Symptoms. — Squamous  epitheliomas  are  usually  found  where  skin 
and  mucous  memVjrane  join  or  at  the  meeting-point  of  two  kinds  of 
epithelimn.  The  situati(jns  which  are  of  special  interest  to  our  subject 
are  the  lower  lip,  nose,  tongue,  gums,  palate,  tonsils  and  pharynx. 
The  digestive,  generative,  and  similar  parts  are  also  affected.  The 
hands  and  feet  rarely. 

The  first  sign  of  its  appearance  is  usually  a  small  indurated  nodule 
just  under  the  epithelium.  Later,  an  irregular  ulcerated  warty  sur- 
face develops,  from  which  occasionally  there  is  a  slight  exudation 
denoting  ulceration  within  a  surrounding  indurated  border.  This 
leads  to  incrustation.  Beneath  the  scab,  if  removed  or  if  it  drops 
off  without  remo\'al,  the  developing  cancer  is  plainly  seen. 


CARCI XOM  A—CAXCER 


475 


Cylin-dric-cell  Epitiielio^l\  (Adenoid  Cancer,  Columnar-cell 
EriTirF.i.K'MA,    Malignant   ADENO^L\). — In   this   variety    there   are 


Fig.    302. — .Squamous  epithelioma  of  the  cheek.     vSectiuu.  ium  case  shown  in  Fig.  30-3.; 


Fig.  303. — Man  with  carcinoma  of  the  cheek  and  lower  jaw.    Fig.  302  shows  a  section 
of  the  growth.    The  scar  of  a  p^e^"ious  ineffective  operation  maj-  be  noted. 

tubular  cavities  in  which  layers  of  cylindric  cells  are  separated  by  a 
stroma.  The  more  nearly  the  appearance  resembles  true  gland  for- 
mation the  slower  the  growth,    "\\lien  it  is  unlike  gland  tissue  and 


476  TUMORS 

the  cells  are  small  and  in  irregular  arrangement,  rapid  growth  and 
recurrence  may  be  looked  for. 

Symptoms.— They  are  more  likely  to  be  found  in  young  patients 
than  other  forms  of  epithelioma,  are  soft  and  gelatinous  and  com- 
monly appear  upon  the  mucous  membranes  of  the  gastro-intestinal 
tract  or  the  uterus.  They  also  appear  in  the  liver,  kidney,  and  other 
organs,  and  may  grow  Aer}-  slowly  or  with  great  rapidity. 

Tubulated  Epithelioma  (Rodent  Ulcer,  Lupus  Exedens, 
ETC.). — This  form  of  epithelioma  has  irregular  pavement  epithelium 
arranged  m  plugs  or  cylinders,  embedded  in  a  stroma  of  connective 
tissue.  The  epithelial  nests  and  pearls  are  not  found  in  these  growths. 
Rodent  ulcer  affects  old  people,  appears  most  frequently  on  the  face, 
tongue,  corner  of  the  nose,  and  in  similar  situations  upon  skin  sur- 
faces. It  usually  grows  very  slowly,  sometimes  for  years  without 
attracting  much  notice,  or  it  may  progress  rapidly  from  the  beginning. 
The  ulceration  upon  the  surface  is  in  most  cases  surrounded  by  an 
elevated,  irregular,  indurated  border. 

2.  Glandular  Carcinoma.^ — This  form  of  carcinoma  is  a  tumor  spring- 
ing from  preexisting  gland  tissue.  The  tendency  of  modern  A\Titers 
is  to  discourage  the  use  of  the  term  scirrhous  or  hard  cancer  and 
encephaloid  or  soft  cancer,  and  other  terms  used  to  describe  different 
degrees  of  consistency  of  the  growth  as  distinct  forms.  The  degen- 
erative processes  which  lead  to  these  structural  alterations  are  them- 
selves so  variable  and  so  intermingled  that  clinically  at  least  they  are 
not  entitled  to  such  positive  and  absolute  distinction. 

The  use  of  the  terms  colloid  or  gelatiniform  carcinoma,  mucoid,  and 
melanotic,  or  ■pigmented  sarcoma,  are  also  more  properly  recognized  as 
different  forms  of  degeneration  and  not  wholly  difi'erent  t\i3es  of  growth. 

Symptoms  of  Glandular  Carcinoma. — Glandular  carcinoma  is  found 
on  mucous  membrane  surfaces,  in  the  digestive  tract,  the  mammary 
gland,  pancreas,  kidneys,  ovaries,  and  similar  situations.  The  tumors 
appear  as  nodular  infiltrating  growths  of  exceedingly  variable  con- 
sistency. Upon  section  the  growth  shows  a  glistening  white  color, 
has  more  or  less  translucency,  and  there  is  a  IxTuph-like  exudation, 
composed  of  albmninous  fluid  containing  degenerative  epithelium  and 
oil-droplets,  that  appears  on  the  surface. 

General  Considerations  and  Etiology.— With  research  laboratories 
throughout  the  civilized  world  actively  engaged  in  the  investigation 
of  the  cause  and  nature  of  cancer,  and  in  the  absence  of  positive  and 
generally  accepted  findings,  it  is  impossible  to  tell  what  complete 
changes  in  the  present  theoretical  structures  in  this  relation  the  near 
future  may  bring.  In  the  meantime  clinical  features,  more  or  less 
uniformly  recognized  by  all  surgeons,  must  receive  due  consideration 
m  addition  to  the  theories  of  cancer  causation  previously  described 
with  reference  to  tumors  (pages  431  to  433). 

Crile,  in  his  oration  on  the  cancer  problem, ^  calls  attention  to  the 

>  Med.  Record,  June  6,  1908. 


CARCINOMA— CAXCER  477 

fact  "that  although  the  cause  of  cancer  still  remains  uiiknowTi,  many 
of  its  phenomena  have  been  carefully  studied.  It  occurs  in  every 
climate  and  among  all  mankind,  savage  and  civilized,  in  wild  and  in 
domestic  animals,  carnivorous  and  herbivorous,  in  birds,  fishes,  reptiles 
even  in  the  lowly  oyster.  Throughout  Nature  the  histological  picture 
of  any  definite  cancer  is  the  same. 

"Although  the  prima^^•  cause  is  not  known,  many  of  the  predispos- 
ing causes  and  precancer  states  are  known  and  can  be  recognized. 
The  growth  of  carcinoma  rarely  follows  a  single  trauma,  but  in  the 
visible  fields  it  is  frequently  preceded  by  chronic  irritations,  by  scars 
and  ulcers,  by  h^-perplasia,  by  chronic  inflammation,  and  by  pre- 
existing benign  growths.  Among  the  benign  growths  predisposing 
to  cancer  let  us  note  fibromas,  papillomas,  adenomas,  and  cysts. 

"^lost  innocent  tim^ors  of  the  parotid  ultimately  become  sarcoma- 
tous.    ]vlany  irritated  moles  freely  metastasize  as  deadly  melanomas." 

Location. — Extract  from  summary  of  Crile's^  operative  cases.  The 
total  niunber  was  132,  of  which  the  following  were: 

Location. 
Carcinoma  of  face  (including  maxillae) 
Carcinoma  of  lips 
Carcinoma  of  floor  of  mouth 
Carcinoma  of  soft  palate 
Carcinoma  of  alveolar  process 
Carcinoma  of  tongue  . 
Carcinoma  of  parotid 


rations. 

Recoveries. 

Deaths 

15 

14 

1 

31 

31 

0 

4 

1 

3 

1 

1 

0 

2 

2 

0 

12 

10 

2 

5 

5 

0 

With  regard  to  the  "cancer  areas"  and  "cancer  houses"  theories 
sometimes  advanced  by  those  who  believe  in  the  infectious  character 
of  cancer,  Simon-  reports  five  deaths  in  an  old  double  farmhouse  in 
Wales.  The  farmer's  wife  died  of  cancer  in  1SS2;  the  daughter-in- 
law-  had  cancer  from  1SS6  to  1890,  when  death  resulted;  the  daughter 
died  of  cancer  in  1S96;  the  woman  who  lived  on  the  other  side  of  the 
house,  who  nursed  one  of  the  women  affected  with  cancer,  herself  died 
of  the  disease  in  1900;  and  this  woman's  husband  died  of  cancer  in 
1903.  Five  deaths  in  different  families  in  the  same  house  between 
1882  and  1903. 

The  fact  that  epithelioma  of  both  lip  and  tongue  is  much  more 
frequent  among  men  who  are  confirmed  smokers  and  who  have  bad 
teeth  is  also  significant,  as  is  the  fact  that  these  growths  grow  in  other 
situations  of  the  mouth  where  diseased  conditions  of  teeth  and  gums 
are  prevalent.  Park  states  that  one-fifth  of  the  cases  of  epithelioma 
of  the  tongue  are  preceded  by  leukoplakia.  In  other  regions  the 
well-know-n  chimney-sw-eep"s  cancer  of  the  scrotum  and  similar  can- 
cers that  are  known  to  occur  frequently  among  those  w'hose  vocations 
expose  certain  surfaces  to  continued  or  unusual  irritation  all  mark 
ver\-  plainly 'the  significance  of  irritation  in  this  regard.  E.  H.  Bash- 
ford,  in  his  report  of  the  experimental  study  of  the  Imperial  Cancer 
Research  at  the  Medical  Congress  in  Budapest,  calls  attention  to  the 

1  Jour.  Am.  Med.  Assn.,  December  1,  1906,  p.  17S5. 
*  Practical  Medicine  Series,  1910,  ii,  116. 


478  TUMORS 

fact  that  by  suitable  technic  it  is  now  possible  to  reproduce  all  the 
lesions  of  cancer  experimentally — -"local  inflammation,  systemic  dis- 
semination, and  the  terminal  cachexia" — and  concludes  that  "it  is 
now  agreed  that  infection  plays  no  part  in  the  experimental  trans- 
ference of  cancer,  which  is  a  true  transplantation  of  living  cells. "^ 

Age. — There  is  undoubtedly  a  predisposition,  or  at  least  a  weak- 
ened resistance,  to  cancer  in  persons  of  advanced  age,  as  evidenced 
by  its  frequent  occurrence  between  the  ages  of  forty-five  and  sixty- 
five  years  and  its  infrequency  in  early  life. 

Murphy's  Laws. — Murphy  has  laid  down  the  following  laws:^ 

"Law  1.  Repeated  mild  traiunas  and  irritations,  particularly  at 
the  border-line  of  different  epithelial  fields  and  cicatricial  tissue,  are 
potent  etiological  factors  in  carcinoma. 

"Law  2.  Moderately  severe  traumas  once  applied  never  produce 
carcinoma. 

"Law  3.  Moderately  severe  traumas — not  to  a  degree  of  laceration 
or  fracture — are  frequently  the  cause  of  sarcoma  and  the  precipitation 
of  tuberculosis. 

"Law  4.  Severe  traumas  to  the  degree  of  laceration  or  fracture 
never  cause  carcinoma,  sarcoma,  or  focalized  tuberculosis. 

"Law  5.  Sudden  changes  in  conformation  and  vascularity,  as 
embryonal  defects,  pigmented  moles,  warts,  papillomas  or  cutaneous 
fibromas  usually  indicate  beginning  malignancy  and  always  demand 
immediate  removal." 

Sjmiptoms.— The  appearance  of  the  different  forms  of  cancer  has 
already  been  briefly  described,  and  is  shown  in  Plates  XIV,  XV  and 
Figs.  304  and  305.  A  general  description  of  the  clinical  picture  of  the 
patients  suffering  from  this  afl^ection,  however,  seems  to  be  required. 

Whether  progressing  by  destructive  ulcerative  process  or  as  a  timior 
mass  involving  the  surrounding  structures,  there  is  always  marked 
tendency  to  lymphatic  infection,  and  the  lymph  nodes  thus  affected 
really  are  in  the  nature  of  metastatic  extensions  which  partake  of  a 
full  measure  of  malignancy. 

Epithelioma  or  carcinoma  springing  from  any  of  the  structures  of 
the  mouth,  such  as  the  lip,  jaw,  gland,  or  tongue,  may  by  extension 
involve  or  include  any  or  all  of  the  other  tissues.  There  is  usually 
little  if  any  pain  until  certain  nerve  fibers  or  branches  of  nerves  become 
affected  or  secondary  inflammatory  processes  create  more  active 
disturbance.  Both-  pain  and  tendency  to  severe  hemorrhage  must  be 
expected  as  the  disease  extends  to  the  large  vessels  as  well  as  nerves. 
In  some  cases  the  general  health  and  appearance  seems  to  be  unim- 
paired for  some  time,  but  as  the  growth  progresses  the  characteristic 
cachexia  appears.  This  is  the  result  either  of  a  poisonous  toxin  inci- 
dent to  the  growth  itself,  or  of  septicemic  conditions  derived  from 
degenerative  processes  within  or  associated  with  the  timior.  The 
growth  causes  a  foul  odor,  and  an  unpleasant  flow  of  saliva  dribbles 

'  Lancet,  September  4,  1909. 

»  Practical  Medicine  Series,  1909,  ii,  96. 


PLATE   XIV 


FIG.  2 


Epithelioma  of  the  Lo^^^er  Lip. 


FIG.  8 


FIG.  A 


Epithelioma  of  the  Lower  Lip,  with  Lips  Closed  and 
Lower  Lip  Everted. 


PLATE   XV 


Carcinoma  of  the  Tongue. 


CA  RCINOMA  —CANCER 


479 


Fii;.  ;;n4. — Section  of  epitheli"iiia  ^i  the  Inwcr  li()  ivnm  ca^e  illu>ii 


t  •  •  •  ~ . »-  .  ;■ 


1  ,ii.  .,ul. 

—     ^ 


Fig.  305. — Section  of  epithelioma  of  the  lower  lip  from  case  illustrated  in 
Figs.  .301  and  304. 


480 


TUMORS 


from  the  mouth  as  the  usefulness  of  the  parts  is  lost,  which,  with  the 
discouragement  of  such  individuals,  makes  the  general  picture  exceed- 
ingly distressing.  Death  usually  results  from  the  invasion  of  some 
vital  part,  from  malnutrition,  or  from  infection. 

Diagnosis. — ^There  are  no  symptoms  of  cancer  which  distinguish 
them  completely  and  absolutely  from  the  pathognomonic  indications 
of  other  affections.  Except  in  cases  in  which  the  growths  are  super- 
ficial and  of  such  form  as  to  be  recognized  by  their  clinical  indications, 
microscopic  sections  give  the  only  definite  means  of  diagnosis.  The 
first  and  most  important  question  is  whether  the  growth  is  benign  or 
malignant  (page  435). 

The  differentiation  between  sarcoma  and  carcinoma  must  then  be 
made.    These  Coplin  has  exhaustively  outlined  as  follows: 


DIAGNOSTIC  FEATURES    OF  SARCOMA  AND  CARCINOMA.^ 


1.  Origin. 

2.  Stroma. 


3.  Cell. 


4.  Intercellular 

substance. 

5.  Vessels. 


6.  Spreads. 


Sarcoma. 

Entirely  mesoblastic  (con- 
nective-tissue type). 

Intercellular.  Rarely  forms 
alveoli. 


Granulation  tissue  or  em- 
bryonic connective-tissue  cells; 
shape  and  size  vary. 

May  be  present 

Embryonic  in  character. 
They  are  in  direct  contact 
mth,  or  may  be  formed  by, 
the  special  cells,  slightly  mod- 
ified, of  which  the  tumor  is 
composed. 

Primarily  and  secondarily 
by  bloodvessels,  rarely  by  the 
lymphatics. 


7. 

Secondary 

Chondroid,  osseous,  calcific; 

changes. 

pigmentary  changes  frequent. 

8. 

Growth. 

Not  invariably  continuous. 
Likely  to  be  interrupted. 

9. 

Site. 

Primarily  in  deep  struc- 
tures; always  from  connec- 
tive tissue. 

10. 

Heredity. 

Seldom  hereditary. 

11. 

Capsule. 

Primarily,  pseudo-encapsu- 
lated; later  infiltrates  the  sur- 
rounding tissue. 

12. 

Fat. 

Rarely,  if  ever,  contains  fat. 

13. 

Age. 

Occurs  most  frequently  be- 
fore middle  life. 

14. 

Injurj'. 

Not  uncommonly  follows 
injury  such  as  trauma. 

Carcinoma. 

Epiblastic  and  hypoblastic 
(epithelial  tissue  type). 

Vascular  connective  tissue 
which  surrounds  and  forms 
the  walls  of  the  alveoli;  these 
communicate  with  one  another 
and  contain  masses  of  epithe- 
lial cells. 

Epithelial  cells  contained 
within  alveoli;  shape  and  size 
vary.  Absent,  or  merely  fluid. 

Absent,  or  merely  fluid. 

Well  developed ;  entirely 
contained  within  the  connec- 
tive-tissue stroma,  and  sup- 
ported by  the  walls  of  alveoli. 
Seldom  in  contact  with  the 
cells. 

Primarily  by  Ij-mphatics, 
except  in  later  stages,  when  it 
may  also  spread  by  bloodves- 
sels, in  which  case  it  spreads 
with  very  great  rapidity. 
Secondarily  by  bloodvessels.* 

Very  rare. 

Rapid,  continuous. 
Never  encapsulated. 


May  be  hereditary. 
Never  encapsulated. 


Nearly  always  contains  fat. 

Most  frequent  after  middle 
life. 

Rarely,  a  history  of  trauma, 
but  may  follow  prolonged 
irritation.  Especially  is  this 
true  of  the  superficial  forms. 


1  Coplin:  Manual  of  Pathology,  p.  363  (after  Woodhead,  modified  and  extended). 


CARCINOMA— CANCER  481 

In  many  cases  malignancy  can  be  diagnosticated  almost  at  a  glance, 
but  in  doubtful  cases  in  which  prompt  and  effective  treatment  might 
produce  good  results  the  difficulties  are  sometimes  trying. 

^Yhen  the  operation  is  performed  in  a  properly  equipped  and  ordered 
hospital  and  section  of  the  tissue  can  be  made  immediately,  frozen, 
studied  under  the  microscope,  and  reported  before  the  patient  has 
come  out  of  anesthesia,  these  difficulties  are,  of  course,  avoided. 

In  other  cases  the  alternative  lies  between  operation  without  full 
knowledge,  with  the  attendant  risk  of  doing  too  much  or  too  little, 
and  the  danger  of  aggravation  by  a  previous  even  though  small  cut- 
ting from  the  growth  for  the  purpose  of  microscopic  study,  with  an 
interval  of  perhaps  a  number  of  days  before  performance  of  the  com- 
plete operation.  How  much  or  how  little  actual  risk  of  converting 
operable  into  inoperable  cases  occurs  in  this  practice  is  impossible  to 
determine  exactly. 

Ryall^  sums  up  this  danger  in  the  following  positive  manner: 

"  In  the  .parent  gro-uth  the  cells  are  more  or  less  encapsulated  in 
fibrous  tissue,  but  some  cells  escape  during  operation  and  find  a  rest- 
ing place  in  the  wound,  which  is  comparatively  unprepared  to  meet 
and  resist  the  invasion. 

"  Cancer  cells  may  escape  during  operation  as  the  result  of  incising 
or  lacerating  the  primary  growth,  cutting  across  or  tearing  an  infected 
lymph  vessel,  or  even  from  rupture  of  a  cancerous  gland,  and  such 
cells  are  quite  capable  of  causing  and  do  frequently  cause  cancer 
recurrence. 

"In  cases  of  doubtful  malignancy,  where  Nature's  barriers  are 
intact,  do  not  remove  a  section  for  examination — remove  the  tmnor 
and  make  the  microscopic  study  afterward."' 

Differentiation  between  some  of  the  infectious  diseases,  notably 
tuberculosis,  may  be  confusing,  as  the  two  are  sometimes  asso- 
ciated. 

The  special  characteristics  of  infectious  diseases  usually  make 
diagnosis  clear,  especially  in  the  field  of  the  mouth  and  jaws,  where 
direct  examination  is  possible.  Hemolysis  has  been  extensively 
tested  to  determine  the  possibility  of  a  positive  or  negative  reaction 
with  regard  to  blood  serum  and  cancer  cells.  The  reports  of  Blum- 
berg,-  Johnson,  Canning,^  Smithy,*  Arnold,^  the  experiments  of  others, 
the  results  of  which  have  come  to  the  author  personally,  and  in  a 
limited  way  tests  upon  his  own  cases  show  that  this  method  cannot 
be  depended  upon  for  diagnosis  in  the  present  state  of  our  knowledge. 
The  antitr\-ptic  index  or  the  power  of  inhibiting  tr^ptic  digestion 
possessed  by  a  serum  as  compared  with  that  of  a  normal  standard 
serum  has  been  investigated  by  Bayly.     He  reports  30  cases,  26  of 

1  Practical  Medicine  Series,  volmne  of  General  Surgerj-,  ii,  121. 
■  Med.  Record,  Januarj-  9,  1909. 

3  JoxiT.  Am.  Med.  Assn.,  October  30,  1909.  *  Ibid. 

5  Yale  Med.  Jour.,  November,  1909,  p.  143. 
31 


482  TUMORS 

which  showed  markedly  raised  index,  3  normal  index,  and  1  subnor- 
mal index,  a  result  evidently  too  uncertain  for  practical  use.^ 

Prognosis. — Prognosis  in  cancer  of  the  lips,  floor  of  the  mouth, 
tongue,  and  jaws  is  grave  to  the  point  of  hopelessness.  Its  future 
aspect  is  more  hopeful  than  records  of  the  past  would  indicate,  and 
earlier  diagnosis  and  prompt  extensive  operation  with  radical  block 
dissection  of  the  neck  promises  much.  Crile^  calls  attention  to  the 
fact  "that  among  48  traced  cases  operated  upon  more  than  three 
years  ago,  in  which  radical  block  section  was  not  made,  9  are  living; 
and  in  12  cases  in  which  block  section  was  performed  more  than 
three  years  ago,  9  are  living."  His  conclusions  in  this  respect  are 
important.  "The  head  and  neck  present  an  exposed  field.  Cancer 
here,  unlike  that  of  the  stomach,  intestines,  or  even  the  breast,  may 
be  recognized  at  its  very  beginning;  in  every  case  it  is  sometimes 
curable  by  complete  excision.  That  the  field  of  regional  metastasis 
is  exceptionally  accessible,  but  cancer  rarely  penetrates  the 'extra- 
ordinary lymphatic  collar  of  the  neck.  As  the  growth  tends  to  remain 
here  localized,  application  of  the  same  comprehensive  block  dissection, 
as  in  the  radical  cure  of  breast  cancer  and  free  utilization  of  the  modern 
researches  of  surgery,  renders  the  final  outcome  in  cases  of  cancer  of 
the  neck  and  head  more  promising  than  that  of  almost  any  other 
part  of  the  body."  « 

Warren^  reports  122  operations  for  cancer  of  the  tongue  and  floor 
of  the  mouth;  16  (14.2  per  cent.)  remained  free  from  recurrence  over 
three  years.  Butlin  reports  197  cases  of  cancer  of  the  tongue;  20 
died  following  the  operation;  22  were  operated  upon  recently;  in  55 
there  was  no  recurrence  for  periods  averaging  from  thirty  to  thirty- 
three  years. 

Dollinger  reports  6  cures  in  58  cases. 

According  to  Warren  the  mortality  varies  with  the  extent  of  the 
operation;  its  lowest  (5  per  cent.)  with  the  intrabuccal  operation, 
and  its  highest  (30  to  35  per  cent.)  in  the  operations  involving  division 
of  the  lower  jaw. 

"A  careful  study  of  4500  cases,  exclusive  of  the  thyroid  gland, 
traced  to  their  original  report  in  literature,  made  for  me  by  Dr.  Hitch- 
ings,  showed  that  in  less  than  1  per  cent,  have  secondary  cancer  foci 
been  found  in  distant  organs  and  tissues."^ 

Treatment  of  Malignant  Growths. — Whenever  possible  the  treat- 
ment of  cancer  should  be  begun  in  the  precancerous  stage,  that  is, 
whenever  there  are  indications  which  by  any  possibility  might  lead  to 
malignancy.     These  should  be  completely  and  thoroughly  corrected. 

Among  the  many  methods  of  treatment  that  have  from  time  to 
time  been  tried,  the  following  have  received  more  or  less  serious 
attention. 

1  British  Med.  Jour.,  October  23,  1909. 

*  Jour.  Am.  Med.  Assn.,  December  1,  1906,  p.  1780. 
8  Ann.  Surg.,  1908,  xlviii. 

*  George  W.  Crile:  Jour.  Am.  Med,  Assn.,  December  1,  1906,  p.  1780, 


CARCINOMA— CANCER  483 

Injections  of  mixed  toxin  of  erysipelas  and  Bacilhis  prodigiosvs  in 
the  treatment  of  sarcoma  are  reported  by  Dr.  William  B.  Coley^  to 
have  checked  the  growth  in  a  considerable  number  of  cases  and  to 
have  effected  more  or  less  permanent  cures  in  at  least  a  few  instances. 
The  number  of  these,  however,  is  hardly  sufficient  to  warrant  depend- 
ence except  when  operation  is  contra-indicated. 

Enzyme  treatment  as  recommended  by  Beard,  injectio  tr^-psini  and 
injectio  amylopsini  respectively,  designed  to  kill  and  digest  the  cancer 
cells,  and  pancreas  gland  extract  containing  tr^'psin,  amylopsin,  and 
lipase  with  the  milk-curdling  ferment,  after  careful  tests  by  Bainbridge,^ 
have  failed  to  check  cancerous  progress. 

Frederick  Gwyer'  uses  the  dried  thymus  gland  of  the  calf,  and  reports 
improvement  as  a  result  of  continued  administration,  sometimes  in 
doses  as  large  as  an  ounce  of  the  powder. 

Park  recommends  the  use  of  thyroid  extract,  5-grain  doses  three  or 
four  times  a  day,  simultaneously  ^nth  the  use  of  the  a:-rays,  claiming 
that  the  latter  enhance  the  efficiency  of  the  thyroid  treatment. 

Radhm.—Ihe  complexity  of  governing  conditions  in  determining 
the  action  of  radium  such  as  variation  in  the  dosage  and  methods  of 
application  by  different  operators,  differences  in  filters,  and  in  the 
effects  of  alpha,  beta,  gamma  and  secondary  rays,  have  led  to  much 
confusion  in  the  reports  of  the  results  of  radium  therapy.  There 
have  been  remarkable  cures  by  its  use,  and  also  many  disastrous 
failures.  The  following  recommendations  by  Doppert,  reported  by 
Ewing^  seem  to  be  along  conservative  lines  CI)  for  early  localized 
cases — radium;  (2)  established,  or  border-line  cases — operation;  (3) 
inoperable  cases — radium;  (4)  advanced  cases — neither  radium  nor 
operation. 

Cancers  of  the  mouth,  tongue,  tonsil  and  pharsnx,  present  uncertain- 
ties for  radiimi  treatment  both  because  of  anatomical  difficulties  and 
great  differences  in  the  character  of  carcinomatous  gro-^ths  in  these 
regions.  Much  progress  is  being  made  in  the  direction  of  overcoming 
these  disadvantages  by  skilful  and  intelligently  applied  treatment. 
Radimn  intoxication  is  a  term  applied  to  the  phenomena  sometimes 
following  long  exposure  to  large  amounts  of  radium.  The  patients 
suffer  from  nausea  and  vomiting,  extreme  muscular  weakness,  feeble 
pulse,  and  diminished  urine.  Ewing  in  calling  attention  to  this 
states  that  "radiimi  in  any  but  experienced  hands,  is  a  dangerous 
agent,"  but  "precautions  should  not  be  permitted  to  stand  in  the  way 
of  the  normal  legitimate  extension  of  the  radium  treatment  of  cancer." 

"In  the  'field'  of  precancerous  lesions,  hypertrophies,  at^-pical 
inflammatory  overgrowths,  warts,  and  polyps  of  mucocutaneous 
junctions,  numerous  leukoplakias,  cer^■ical  erosions,  nevi,  and  many 

»  Ann.  Surg.,  December,  1908,  xl,  465. 

*  Scientific  Report  New  York  Skin  and  Cancer  Hospital,  ip09. 
'  Ann.  S\iTg.,  jlvii,  506. 

*  JoUT.  Am.  Med.  Assn.,  April  28,  1917, 


484  TUMORS 

accessible  benign  tumors,  radium  is  both  efficient  and  comparatively 
free  from  danger." 

Injections  into  the  growth  of  soap,  potassium,  and  sodium  and  the 
internal  administration  of  many  drugs  have  all  in  course  of  time  been 
tried  and  found  wanting.  The  use  of  plasters  and  pastes  of  arsenic 
destroy  the  surface  in  superficial  growths  upon  which  such  paste  can  be 
safely  applied,  and  have  sometimes  proved  beneficial.  The  serious 
tissue  destruction  from  the  use  of  the  arsenic,  which  after  all  does  no 
more  than  other  less  advantageous  agents,  is,  however,  objectionable. 

Liquid  air  has  been  used  to  freeze  and  destroy  such  tumors.  In 
favorable  cases  it  has  caused  the  scab  to  slough  away  with  sufficient 
tissue  to  cause  cicatrization  of  the  underlying  tissues  without  recur- 
rence. 

The  actinic  rays  of  the  sun  were  utilized  in  one  case  of  M'hich  the 
author  has  personal  knowledge.  It  was  a  rodent  ulcer  at  the  angle  of 
the  nose  which  had  been  removed  by  slight  operations  four  or  five 
times  with  repeated  recurrence.  The  patient,  a  man,  aged'  about 
seventy  years,  spent  many  hours  each  day  with  the  sun's  rays  focussed 
upon  the  ulcer  with  a  magnifying  glass,  allo^^'ing  it  to  burn  as  long  as 
he  could  support  it ;  after  waiting  a  few  moments  for  relief,  he  would 
burn  it  again.  In  the  course  of  a  few  months  the  scab  came  away, 
leaving  the  skin  surface  smooth  and  clean  beneath,  better  than  it 
ever  appeared  after  removal  by  operation,  and  for  a  longer  time  with- 
out recurrence,  although  it  did  recur. 

Ultraviolet  or  "Finscn  lighf'hsis  proved  beneficial  in  some  cases,  but 
the  number  is  too  limited  for  it  to  be  considered  a  valuable  method 
of  treatment. 

X-ray  treatment  is  by  far  the  best  agent  exclusive  of  the  knife. 
Unscientific  use  of  the  Roentgen  rays  through  undertaking  to  do 
the  impossible,  and  ignorance  of  its  character,  the  dosage,  and  other 
matters  which  are  now  thoroughl}-  understood  by  those  competent 
to  undertake  this  kind  of  treatment,  at  first  caused  much  disappoint- 
ment. It  seems  clearly  established  that  upon  skin  surfaces  uhere 
the  growth  can  be  directly  reached  by  the  rays,  their  curative  powers 
are  remarkable.  Rodent  ulcers,  epithelioma  of  the  lip  at  a  sufficiently 
early  stage,  and  cancerous  growths  in  other  similar  situations  can  be 
effectively  controlled.  As  both  the  skin  and  mucous  membrane  act 
to  some  extent  in  the  nature  of  insulators,  the  .r-rays  do  not  alwaj^s 
effectively  penetrate  the  deap-seated  growths  or  deeper  portions  of  the 
growth.  Used  in  after-treatment  directly  upon  the  tissues  after  oper- 
ation, as  described  in  connection  with  the  author's  cases  (page  492), 
x-rays  are  highly  beneficial  and  should  be  a  routine  measure  in  almost 
every  case. 

The  Percy  method  of  the  long-continued  application  of  a  degree  of 
heat,  low  enough  not  to  destroy,  to  any  considerable  extent,  normal 
tissue  cells,  but  of  sufficiently  high  temperature  to  cause,  as  has  been 
shown  that  it  ^^ill,  the  destruction  of  cancer  cells,  has  opened  a  wide 


CARCINOMA— CANCER 


485 


field  of  useful  treatment,  especially  in  inaccessible  situations.  This 
is  particularly  tiue  of  the  treatment  of  neoplasms  in  the  region  of  the 
mouth  and  jaws.  Percy's  equipment  for  this  purpose  is  very  com- 
plete, and  is  now  quite  generally  used. 

Burning,  to  destroy  the  cancer  and  surrounding  tissue,  is  a  valuable 
method  when  it  can  be  thoroughly  applied. 


Fig.  306. — Water-cooled  retractor  in  place;  wooden  spatula  pi'otecting  tongue  pre- 
paratory to  cauterization  of  epithelium,  alveolar  margin  and  cheek,  as  used  by  Dr. 
Gordon  B.  New. 


Extirpation. — ^The  one  hopeful  remedy  at  the  present  time  lies  in 
complete  and  thorough  excision  of  the  growth,  and  "block"  operation 
upon  the  lymphatic  channels  by  which  the  part  is  drained. 

Operative  Treatment. — The  varieties  of  operation  for  removal  of 
malignant  growth  of  the  lips,  tongue,  floor  of  the  mouth,  cheek  and 
jaws  may,  in  a  general  way,  be  divided  as  follows:  (1)  Intrabuccal. 
(2)  Inframaxillary.  (3)  Division  of  the  mandible.  (4)  Resection  of 
the  jaws. 

Cancer  of  the  Lip. — In  removal  of  all  forms  of  cancer,  care  should 
be  taken  not  to  allow  the  knife  to  touch  the  cancerous  tissue.  A  wide 
excision  should  be  made,  if  possible.    There  should  be  at  least  one  inch 


486 


TUMORS 


of  tissue  beyond  the  line  of  demarcation  of  the  growth.  The  author's 
method  of  closure  after  extensive  excision  of  cancer  of  the  lower  lip 
is  shown  in  Figs.  307,  308  and  309.     By  carrying  the  skin  and  fascia 


Fig.  307. — Method  of  closure  of  wound  after  extensive  removal  of  tissue  from  the 
anterior  part  of  lower  jaw  and  lower  lip.  The  parts  are  dissected  free  down  to  the  dotted 
line. 


Fig.  308. — The  parts  closed  and  the  labial  border  restored  by  suturing  skin  and  mucous 

membrane. 


CARCINOMA— CANCER 


48? 


from  beneath  the  jaw,  where  there  is  always  an  abundance  gives  the 
least  possible  deformity.  After  removal  of  a  considerable  portion 
of  the  prolabimn  ver}'  satisfactory  plastic  repair  can  be  obtained  by 
suturing  the  mucous  membrane  to  the  skin  border  along  the  outline 
of  the  mouth  as  reproduced  by  the  newly  placed  tissue.  When  this 
is  not  done,  an  unsightly  and  unyielding  cicatricial  border  results, 
but  with  the  mucous  membrane  carefully  carried  o\'er  and  neatly 
sutured,  a  very  fair  reproduction  of  the  original  vermilion  border  can 
be  secured.  In  all  these  cases,  even  though  the  cancer  upon  the 
lip  be  small,  the  lymphatics  in  the  submental  region  upon  the  affected 
side  must  be  removed.  In  advanced  cases  there  should  be  Crile's 
block  section,  including  the  removal  of  the  glands  in  both  upper  and 
lower  triangles  of  the  neck:  u'hen  the  growth  is  close  to  the  median 
line  this  should  be  done  upon  both  sides  (Figs.  310  and  311). 


Fig.  309. — Result  of  operation  on  lower  jaw  and  lip  performed  as  shown  in  Figs.  307 

and  308. 


This  dissection  of  the  avenues  of  hTnphatic  drainage  is  required 
in  all  forms  of  cancer  of  the  lips,  tongue,  floor  of  the  mouth,  cheeks, 
and  maxillte.  It  is  best  performed  in  two  stages  with  the  mouth 
operation  first  and  removal  of  the  glands  as  soon  after  as  the  patient 
has  sufficiently  recovered  to  bear  the  operation.  (Some  operators 
reverse  this  order  of  procedure,  claiming  that  the  removal  of  the  glands 
first  reduces  the  danger  of  mestastatic  extension.)  The  danger  of 
shock  and  infection  are  both  reduced  in  this  way,  and  the  records  show 
a  correspondingly  marked  decrease  of  mortality.  Butlin's  mortality 
in  13  cases  was  23  per  cent.,  as  opposed  to  7  per  cent,  mortality  when 
the  operation  was  performed  in  two  stages. 

Crile  reports  only  one  fatality  in  his  last  72  major  operations  in 
this  field  as  a  result  of  better  protection  of  patients  from  chilling, 
the  employment  of  skilled  anesthetists,  and  other  means  to  prevent 
and  overcome  shock  and  decrease  the  number  of  infections  and  pneu- 
monia. 


488 


TUMORS 


Fig.  310. — Block  section  for  the  removal  of  glands  in  both  upper  and  lower  triangles  of 
ll^the  neck.     (After  Crile.)|    _  ^   _^_  L-- 


Fig.  311. — Block  section  for  removal  of  glands  in  both  upper  and  lower  triangles  of  the 

neck.     (After  Crile.) 


PLATE    XV ; 


Lids, 
ner  half 

q^IjH        Nasal   Cauity 
behind 


Upper '^^^^y. 
Jaw 


Lids, 
outer  iicilf  Pharyn 


DeepyJUuaclea 

of    Pkad 

Scalp 

y\ 

behind  Ear 

X  \ 

Cheek, 
outer  swV/ace 


External 
Ear 


_  So/t_ — ---— -^-iU.^       Tonsil 
n;  \  Tongue  o" 


Pharynx, 
wer  part 


beep  Musch 
of  Neck 


Level  of  upper  border 

of   Thyroid  Cartilage 


i-    Larynx 


Connects  with 

Superior 

Mediastinal  Glands 


Diagram  of  the  Nodes  and  Vessels  of  the  Head  and  Neck, 
sho\A/ing  the  Regions  that  are  Drained  into  Each  Group  of 
Nodes.     (Gerrish.) 

Deep  structures  in   red,  superficial    in   black. 


PLATE   XVII 


-Li\l 


>  B 


■\A    7f| 


i 


% 


•~-K 


Anterior  Vie^A^  of  Lymphatics  of  the  Tongue,     (von  Bergmann.) 

The  anterior  portions  of  the  digastric  and  the  geniohyoid  muscles  have  been 
removed.  A  large  window  has  been  cut  in  the  mylohyoid  and  the  genioglossi  muscles 
pulled  apart.  On  the  right  side  the  lymphatic  vessels  which  empty  into  the  deep 
cervical  glands  and  pass  between  the  genioglossi  are  shown  (G,  F,  E,  E).  On  the  left 
side  the  lymphatics  of  the  tongue  which  empty  into  the  submaxillary  glands  {A,  B,  C) 
are  shown  above.  Below  at  /,  K  are  seen  the  terminal  lymph  vessels  of  the  deep 
cervical  glands  emptying  into  the  large  venous  trunks. 


CARCINOMA— CANCER  489 

Cancer  of  the  Tongue. — Whitehead's  Ojjeration  for  Removal  of  the 
Tongue. — For  unilateral  resections,  the  frenum  and  mucous  membrane 
on  one  side  of  the  tongue  are  divided.  The  dorsum  of  the  tongue  is 
incised  through  the  median  line  and  split  along  the  raphe.  Tension 
is  then  made  by  drawing  the  divided  portion  upward  and  forward 
until  the  geniohyoglossus  muscle  is  stretched  to  its  fullest  extent. 
This  is  divided  close  to  its  point  of  origin;  the  tongue  may  then  be  drawn 
so  far  out  of  the  mouth  as  to  make  it  easily  accessible  for  operation. 
When  the  entire  tongue  is  to  be  removed,  or  on  both  sides  of  the 
anterior  portion,  the  tissues  are  freed  by  making  the  same  incisions 
upon  both  sides. 

The  lymphatic  systems  of  the  mouth  and  neck  are  shown  in  Plates 
XVI  and  XVII.  It  is  important  to  note  that  the  base  of  the  tongue 
is  practically  separate  from  the  body  of  the  organ,  and  that  its 
lymphatic  vessels  empty  through  the  system  in  connection  with  the 


d/K^^S^ 


w 


-■■■■•■^m^ 


Fig.  312.— Inframaxillary  removal  of  the  tongue.     (Kocher.) 

submaxillary  glands,  whereas  the  lymphatics  of  the  anterior  part  of  the 
tongue  find  their  avenues  of  connection  through  the  cervical  glands. 
This  makes  it  possible  to  spare  the  posterior  portion  of  the  tongue  in 
operation  for  the  cancer,  and  as  lymphatic  anastomosis  across  the 
median  raphe  occurs  imperfectly  if  at  all  in  the  early  stages,  at  least 
cancer  is  usually  limited  to  one  side  or  the  other  of  the  median  raphe. 
The  lymphatics  of  the  floor  of  the  mouth  and  of  the  submaxillary 
lymphatic  glands  are  in  intimate  relation  and  following  in  order.  The 
superficial  and  deep  cervical  glands  complete  the  chain. 

Inframaxillary  Operations.— /voc/^er'^  Operatiori. — A  curved  incision 
is  made  from  the  chin  to  the  ear,  with  its  lowest  point  close  to  the 
hyoid  bone.  The  mouth  is  entered  below  the  jaw  by  division  of  the 
mylohyoid  muscle  after  dissecting  free  the  submaxillary  gland.  The 
tongue  and  floor  of  the  mouth  are  removed  below  the  jaw,  together 
with  the  lymphatics  in  the  submental  region  (Fig.  312). 


490  TUMORS 

Temporary  resection  of  the  jaws  for  this  purpose  is  described  on 
page  384. 

Warren  reports  45  cases  of  cancer  of  the  tongue  with  seven  cures 
at  the  end  of  five  years  or  longer  (15.5  per  cent.). 

Cancer  of  the  Lower  Jaw, — Operation  for  cancer  of  the  mucous  mem- 
brane and  alveolar  process  of  the  lower  jaw,  involving  the  bone,  show 
a  high  mortality. 

Warren^  reports  40  operations  upon  these  cases  at  the  Massachusetts 
General  Hospital,  10  deaths  as  a  result  of  the  operation  (35.7  per  cent.), 
and  of  these,  within  a  five-year  limit,  there  were  but  three  cures. 
(See  Resection  of  Lower  Jaw,  page  384.) 

The  operations  performed  upon  these  40  cases  were  as  follows: 

Operative 
Cured.  deaths. 

Resection  alone,  12 1  5 

Resection,  neck  dissection,  4 1  2 

Resection,  neck,  other  parts,  3 1  1 

Minor  operations,  7 2  2 

Cancer  of  Upper  Jaw. — See  Resection,  page  393. 

Cancer  of  the  Cheek. — ^The  incisions  for  cancer  of  the  cheek  cannot 
follow  any  definite  rules,  but  must  be  governed  by  the  form  and  extent 
of  the  growth.  After  the  growth  is  completely  removed,  the  open 
surface  of  the  wound  may  be  closed  by  plastic  operation  at  a  later 
operation  if  necessary.  In  these  cases  the  .r-rays  can  be  advantageously 
applied  directly  to  the  unclosed  wound  surface. 

Cancer  of  the  Palate. — Resection  of  the  jaw  as  described  (page  384) 
may  be  required  to  expose  the  palatal  region  completely. 

Cancer  in  the  Region  of  the  Maxillary  Sinus.^In  the  author's  opinion 
this  can  best  be  treated  by  A.  J.  Ochsner's  method,  which  he  has  been 
kind  enough  to  describe  in  a  special  letter  as  follows : 

"We  simply  cut  away  with  a  chisel  all  of  the  diseased  tissue  that 
we  can  find  and  then  cauterize  the  surface  furiously  with  an  ordinary 
soldering  iron,  which  is  heated  to  red  heat,  until  every  particle  of 
diseased  tissue  as  far  as  one  dares  to  burn  has  been  destroyed.  Then 
we  pack  the  cavity  with  the  following  solution:  20  grains  of  bicar- 
bonate of  soda,  I  ounce  of  salicylic  acid,  3|  ounces  of  chloride  of  zinc, 
and  enough  commercial  alcohol  to  make  half  a  pint.  A  little  of  this 
is  placed  in  a  small  glass  and  a  piece  of  gauze  saturated  in  the  solution, 
but  not  sufficiently  to  cause  it  to  drip.  This  is  packed  into  the  cavity 
and  over  it  a  dry  piece  of  gauze  is  packed  to  take  up  all  of  the  moisture 
which  may  escape.  This  packing  is  removed  on  the  second  or  third 
day,  and  from  that  time  on  the  cavity  is  packed  with  formalin  gauze 
and  is  kept  clean  by  irrigation." 

The  case,  a  man,  aged  fifty-four  years,  was  referred  to  the  author 
with  an  opening  through  the  buccal  wall  of  the  maxillary  sinus,  with 
slight  evidence  of  ulceration  of  soft  tissues  at  the  borders.  The  usual 
treatment  by  previous  ineffective  irrigation  through  the  mouth  and 

1  Am.  Surg.,  1908,  xlviii,  503. 


CARCINOMA— CANCER  491 

nose  had  been  tried  for  some  time  previously.  As  there  was  no  cHnical 
evidence  of  mahgnancy  at  this  time,  a  radical  operation  for  empyema 
of  the  maxillary  sinus  was  performed.  The  tissue  healed  quickly  and 
the  patient  made  an  uninterrupted  recovery.  As  a  matter  of  precau- 
tion an  elliptical  section  was  taken,  including  the  tissue  all  around  the 
opening  into  the  sinus  before  enlargement  was  performed  in  course 
of  the  operation.  Sections  from  this  under  the  microscope  looked 
suspicious.  Some  six  months  later  the  growth  reappeared  in  this 
region  and  this  time  was  plainly  shown  to  be  carcinoma.  There 
appeared  to  be  two  alternatives  in  treatment:  one,  a  complete  resec- 
tion of  the  superior  maxilla,  with  its  almost  certain  deformity,  the 
other,  Ochsner's  burning  method,  which  would  leave  practically  no 
deformity.  The  patient  was  referred  to  Dr.  Ochsner,  who  operated 
by  using  a  series  (approximately  20)  of  red-hot  soldering  irons,  with 
which  he  burnt  the  tissue  in  all  directions.  This  was  done  from  within 
the  mouth  without  an  external  incision.  Dr.  Ochsner's  claim  that  as 
much  tissue  could  be  removed  without  deformity  by  actual  burning 
as  would  be  taken  out  by  resection,  with  its  greater  deformity  and 
more  risk,  and  that,  in  addition  to  this,  sloughing  of  the  burn  would 
continue  as  the  area  of  tissue  destroyed  would  be  increased  by  slough- 
ing and  bone  exfoliation  far  beyond  the  actual  outline  of  the  first  wound, 
thus  antagonizing  the  formation  of  new  cancer  cells,  was  fully  borne 
out  by  the  result.  A  packing  of  muliptol  was  inserted  and  changed 
daily,  bringing  away  from  time  to  time  masses  of  exfoliated  bone  and 
sloughing  soft  tissue.  A  second  burning  was  necessary  after  several 
months  because  of  recurrence,  but  since  that  time,  a  matter  of  four 
years,  the  patient  has  been  quite  free  from  growth  of  this  region,  and 
he  has  suffered  neither  deformity  of  the  external  face  nor  serious 
inconvenience  through  the  loss  of  teeth  and  alveolar  process  which 
has  been  supplied  by  a  dental  plate.  In  the  author's  opinion  this 
growth  could  not  have  been  checked  as  well  by  any  other  method. 

This  method  of  deep  burning  has  undoubtedly  a  wide  field  of  appli- 
cation in  dealing  with  malignant  growths  of  the  jaws  in  other  situations 
as  well  as  the  maxillary  sinus,  but  this  particular  case  has  been  chosen 
for  illustration  because  of  the  well-known  difficulties  encountered 
in  complete  extirpation  of  rapidly  growing  cancer  in  this  region.  A 
later  report  of  this  case,  approximately  nine  years  after  treatment, 
shows  that  there  have  been  no  recurrence  of  the  grouth.  Without 
treatment  he  could  hardly  have  lived  six  months. 

Practical  Results  of  the  Use  of  the  X-rays  after  Operation. — Cancer  of 
the  lip,  as  has  already  been  stated,  requires,  in  addition  to  the  side 
removal  of  the  affected  lip  tissue,  removal  of  the  lymphatic  glands 
under  the  jaw.  In  most  cases  it  is  safer  to  remove  the  glands  of  the 
neck  upon  the  affected  side  also.  When  genuine  evidence  of  malig- 
nancy is  present  in  any  of  these  glands,  it  is  safer  not  to  close  the  skin 
surface  immediately,  but  by  opening  the  flap  to  enable  the  a:-rays 
to  be  used  directly  upon  the  recently  exposed  surface. 


492  TUMORS 

It  is  well  known  that  both  skin  and  mucous  membrane  resists  the 
penetration  of  the  rays.  Upon  actual  skin  surfaces  or  upon  directly- 
exposed  tissue,  however,  ;r-rays  destroy  malignant  tendency. 

One  of  the  author's  patients,  a  man,  aged  fifty-two  years,  gave  a  his- 
tory of  the  formation  of  an  ulcer  at  the  border  of  his  lower  lip.  It  had 
continued  despite  the  application  of  salves  for  a  period  of  about  ten 
years,  when  an  operation  was  performed  by  the  usual  elliptical  excision  of 
lip  tissue.  As  might  have  been  expected,  this  was  practically  a  failure 
and  caused  greater  deformity  than  would  have  resulted  from  a  mire 
extensive  properly  performed  operation.  One  cervical  gland  on  the 
affected  side  had  also  been  operated  upon  for  an  abscess,  but  no  record 
of  its  nature  was  available.  Upon  examination  the  author  found  cancer 
affecting  the  lower  lip  and  the  gum  tissue  adjoining  the  lower  incisor 
teeth.  There  were  no  enlarged  glands  apparent,  either  in  the  sub- 
maxillary or  cervical  region.  The  tongue  was  not  affected.  Operation 
was  performed  by  wide  removal  of  tissue,  including  the  lower  lip  to 
and  beyond  the  median  line  down  to  the  chin,  as  shown  in  Fig.  307. 
The  teeth,  alveolar  structures,  and  the  anterior  plate  of  the  lower 
jaw,  including  the  overlying  tissues,  were  removed  with  a  surgical 
engine  bur,  including  also  the  cancellous  structure  of  the  bone.  The 
compact  bony  structure  of  the  inner  surface  of  the  jaw  was  left  with  a 
clean,  smooth,  hard  surface.  Over  this  the  external  wound  was  closed 
according  to  the  author's  method,  as  shown  in  Fig.  308.  Prompt 
healing  followed.  The  parts  seemed  to  be  entirely  free  from  the  old 
affection,  and  bridge-work  was  inserted  by  Dr.  Percy  B.  Wright,  of 
Milwaukee,  which  was  attached  to  the  remaining  bicuspid  teeth.  It 
was  composed  of  vulcanized  rubber,  which  would  permit  of  adjustment 
from  time  to  time  as  the  form  of  underlying  tissues  changed.  For  the 
sake  of  cleanliness  and  convenience  this  was  made  removable,  and  the 
gold  crowns  which  held  it  in  place  were  made  to  slip  over  other  crowns 
which  had  previously  been  cemented  to  the  bicuspids.  The  result  is 
shown  in  Fig.  309.  Instruction  was  given  to  have  the  cervical  glands 
removed  at  an  early  day.  At  a  subsequent  operation  some  time  later 
(six  months)  the  submaxillary  and  cervical  glands  were  removed  by 
Dr.  John  L.  Yates,  of  Milwaukee,  and  it  was  found  then  that  cancer 
was  evident  as  far  as  the  clavicle,  because  the  patient  did  not  have 
an  early  operation  as  directed.  Treatment  with  the  .x-rays  by  Dr. 
Otto  K.  Foerster  and  Dr.  Baer,  of  Milwaukee,  during  a  period  of  several 
weeks,  with  the  skin  edges  ununited  and  turned  back,  resulted  in 
shrinkage  of  tissue  until  not  the  faintest  semblance  of  malignancy 
remained  anywhere.  About  this  time  recurrence  of  the  growth  upon 
the  site  of  the  author's  first  operation  upon  the  lower  lip  became  evi- 
dent. This  was  opened,  a  wide  excision  performed,  and  allowed  to 
remain  exposed  to  the  .r-rays,  which  were  used  triweekly  with  varied 
dosage.  For  a  considerable  time  the  use  of  the  a:-rays  in  this  manner 
seemed  to  be  completely  effective,  but  recurrence  and  death  ultimately 
occured.     The  dire  results  of  neglecting  ulcers  on  skin  surfaces  that 


CARCINOMA— CANCER 


493 


show  tendency  to  become  chronic,  whether  there  be  evidence  of  unmis- 
takable mahgnancy  or  not,  and  the  futiHty  of  ineffective  operations 
according  to  old  methods  of  excising  a  small  portion  of  the  lip  and 
allowing  the  lymphatic  glands  to  remain  untouched,  is  very  strikingly 
brought  to  notice.  It  is  almost  invariably  advisable  to  operate  upon 
the  lip  and  mouth,  and  to  perform  a  "block"  dissection  of  the  lym- 
phatics, as  recommended  by  Crile,  as  soon  as  the  patient  has  suffi- 
ciently recovered  to  make  operation  upon  the  neck  safe.  Operation 
for  resetion  of  the  jaws  is  described  on  pages  384,  385  and  389  in 
connection  with  operations  upon  the  maxillae. 


Fig.  313. — Section  of  cancer  in  case  of  a  man,  aged  sixty-one  years,  that  involved 
the  lip,  jaw,  sublingual  glands,  and  alveolar  structures,  which  was  treated  as  pyorrhea 
alveolaris  for  a  long  period  of  time  until  properly  diagnosticated. 


Fig.  313  is  a  section  of  a  growth  which  is  an  example  that  should 
be  particularly  borne  in  mind  by  dentists.  The  patient,  a  man,  aged 
sixty-one  years,  was  treated  by  a  dentist  for  so-called  pyorrhea  alveo- 
laris affecting  the  lower  incisor  teeth.  These  were  later  removed  and  a 
piece  of  bridge-work  inserted.  A  tendency  to  persistent  disease  of  the 
mucous  membrane  under  the  bridge  was  treated  for  some  months. 
Quite  by  chance  he  came  under  the  care  of  another  dentist,  who 
immediately  removed  the  bridge- work  and  advised  proper  examination. 
When  referred  to  the  author  there  was  evidence  of  a  slight  progressive 
ulceration  involving  the  gum  and  mucous  membrane  in  the  anterior 
part  of  the|jaw.  Sections  of  tissue  from  the  gum,  sublingual  glands, 
under  surface  of  the  tongue,  other  portions  of  the  floor  of  the  mouth, 


494  TUMORS 

and  adjoining  border  of  the  lip  showed  carcinoma.  Thus  under  the 
very  eyes  of  the  dentist  the  case  had  progressed  from  a  simple  condi- 
tion to  the  point  of  utter  hopelessness,  because  proper  treatment  would 
have  meant  complete  resection  of  the  lower  jaw,  removal  of  the  tongue 
and  floor  of  the  mouth  and  glandular  structures  throughout  the  neck, 
with  little  hope  of  survival  and  none  for  future  comfort. 

Both  surgeons  and  dentists  should  be  on  the  lookout  for  malposed, 
impacted,  or  unerupted  teeth,  especially  late  in  life,  and  use  the  .r-rays 
whenever  necessary  to  determine  their  presence. 

The  following  cases  of  the  author  were  allowed  to  reach  a  hopeless 
condition  before  the  cause  was  discovered. 

A  woman,  aged  sixty  years,  gave  a  history  of  necrotic  condition 
of  the  lower  jaw,  which  was  due  to  an  unerupted  tooth.  Its  removal, 
however,  was  not  accomplished  until  carcinoma  was  well  under  way 
and  had  involved  other  structures  extensively. 

A  woman,  aged  seventy-one  years,  had  worn  artificial  dentures 
for  many  years.  A  cuspid  tooth  was  found  lying  close  under  the  floor 
of  the  nose,  and  resulted  finally  in  sarcoma  and  death. 

A  man,  aged  about  thirty-seven  years,  had  an  impacted  lower  third 
molar.  Before  coming  under  the  author's  care  the  disease  had  pro- 
gressed beyond  operative  limitations. 

If  the  first  sources  of  irritation  had  been  discovered  in  these  cases 
before  malignancy  developed,  the  author  believes  there  would,  in  all 
probability,  have  been  no  malignancy  in  that  region.  Even  if  dis- 
covery had  not  occurred  before  this  prompt  diagnosis  would  have 
made  it  possible  to  operate  successfully. 


CHAPTER  IX. 
DISEASES  OF  THE  MAXILLARY  SINUS. 

In  the  light  of  present  knowledge  of  the  nasal  accessory  sinuses 
in  man  it  is  evident  that  pathological  conditions  of  the  maxillary  sinus 
are  so  often  intimately  related  to  diseases  of  the  other  accessory  sinuses 
that  both  the  etiology  and  treatment  of  any  one  of  them  must  be  more 
or  less  governed  by  the  influence  of  others  that  may  be  involved. 

A  chapter  devoted  to  consideration  of  the  maxillary  sinus  would 
therefore  be  out  of  place  in  this  work,  without  description  in  detail 
of  the  surgical  and  therapeutic  measures  required  for  the  treatment  of 
each  one  of  the  accessory  nasal  sinuses,  were  it  not  for  the  fact  that 
the  maxillary  antrum  has  also  an  important  relation  to  diseases  of  the 
buccal  cavity.  These  can  best  be  understood  and  diagnosticated 
by  those  whose  training  has  made  them  conversant  with  affections  of 
the  jaws  and  teeth,  and  it  is  of  the  utmost  importance  that  the  subject 
be  given  the  fullest  possible  prominence  from  this  point  of  view. 

The  author  is  deeply  impressed  with  the  urgent  need  of  develop- 
ment of  maxillary  sinus  treatment  along  these  lines;  he  is  also  no  less 
convinced  that  operations  upon  the  frontal,  ethmoidal,  and  sphenoidal 
sinuses  and  cells  can,  for  the  greater  part,  be  more  successfully  per- 
formed by  operators  whose  field  of  practice  is  confined  to  the  nose 
and  its  diseases;  therefore  the  reader  is  referred  to  the  works  of  this 
character  for  more  complete  description  of  operations  upon  these 
sinuses. 

For  many  reasons  this  line  of  demarcation  is  not  clearly  defined. 
Many  cases  could  be  cited  in  which  some  undiscovered  septic  condition 
of  the  mouth  has  caused  recurrence  and  continuance  of  maxillary 
sinus  disease  in  spite  of  repeated  and  otherwise  perfectly  performed 
operations  by  those  who  were  unfamiliar  with  pathological  affections 
of  the  oral  cavity  and  its  associated  parts.  On  the  other  hand,  an 
equal  or  perhaps  greater  nimiber  might  be  described  in  which  long 
suffering  and  ultimate  disaster  were  brought  about  through  failure  to 
diagnosticate  and  establish  a  cure  of  disease  of  the  nose  or  nasal 
accessory  sinuses.  The  operator,  though  skilled  in  mouth  treatment, 
could  not  do  without  aid,  which  was  not  sought  at  a  sufficiently  early 
date,  detect  the  existence  of  the  counteracting  conditions. 

The  author's  purpose  is  to  cover  the  subject  of  the  maxillary  sinus 
and  its  diseases  in  all  respects  as  to  make  possible  a  more  general 
common  understanding  of  the  important  features  of  these  affections. 
This  he  hopes  will  lead  to  a  more  satisfactory  cooperation  than  there 

(495) 


49G 


DISEASES  OF  THE  MAXILLARY  SINUS 


has  been  in  the  past  between  dentists,  rliinologists,  specialists  in  sinus 
operations,  and  oral  surgeons,  to  the  end  that  better  results  from 
treatment  may  be  assured. 


Hiatus 
semiluminari. 


Middle  ethmoidal 
cells. 


.Crystalline  lenses. 


X'ncinate  process, 
f  Middle  turbinated 

lione. 
"Middle  meatus. 
'Maxillary  siuus. 
luferifir  meatus, 
lute liov  turbinated  bone 


Vestibule  of  mouth. 
First  molar. 


■Distal  root  first  molar. 


luferior  dental  nerve. 


Fig.  314. — Anterior  view  of  a  vertical  transverse  bilateral  section  of  the  head,  showing 
the  relations  of  the  jaws  and  indicating  the  positions  of  the  turbinates,  antra,  etc. 


Anatomical  Considerations. — The  maxillary  sinus  (antrum  of  High- 
more)  is  the  largest  air  cavity  associated  with  the  nasal  chamber 
(Fig.  314).  It  is  situated  in  the  body  of  the  maxilla  on  each  side. 
The  shape,  size,  and  thickness  of  its  walls  vary  greatly  in  different 
individuals  and  frequently  upon  the  two  sides  of  the  same  indi\idual. 
The  controlling  influence  in  this  respect  may  be  said  to  be  age,  race, 
the  presence  or  absence  of  teeth  and  tooth  germs  within  the  jaw,  and 
developmental  conditions  influencing  surrounding  bones.  It  is  lined 
with  mucoperiosteiun  surmounted  by  ciliated  epithelium.  The 
typical  sinus  is  pyramidal  in  shape,  the  apex  being  toward  the  malar 
bone. 


NASAL  ETIOLOGICAL  FACTORS  497 

Schaeffer^  gives  the  following  averages  based  on  the  measurements 
of  90  adult  specimens : 

Millimeters. 

Dorsosuperior  diagonal 38.0 

Ventrosuperior  diagonal 38.5 

Supero-iuf  erior 33.0 

Ventrodorsal 34.0 

Mediolateral 23.0 

The  five  walls  are  the  inferior  (floor),  anterior  (facial),  posterior 
(zygomatic),  superior  (roof  or  orbital),  and  proximal  (nasal). 

The  ostium  maxillare,  an  oval-shaped  foramen  usually  situated  on 
the  upper  anterior  portion  of  the  proximal  wall,  gives  communication 
between  the  sinus  and  the  nasal  fossa  through  the  hiatus  semilunaris. 

Partial  bony  or  membranous  septa  extend  across  the  sinus  in  some 
cases,  and  are  a  frequent  source  of  trouble  in  treatment.  Whether 
these  ever  are  complete,  as  claimed  by  some  authors,  is  still  a  matter 
of  more  or  less  uncertainty. 

Eminences  upon  the  floor  mark  the  outline  of  the  roots  of  teeth, 
which  are  sometimes  in  direct  communication  with  the  sinus. 

Classification  of  the  Diseases  of  the  Maxillary  Sinus. — (1)  Acute 
catarrhal  maxillary  sinuitis;  (2)  chronic  catarrhal  maxillary  sinuitis; 
(3)  acute  suppurative  maxillary  sinuitis;  (4)  chronic  suppurative 
maxillary  sinuitis  or  chronic  empyema  of  the  maxillary  sinus;  (5)  dis- 
eases of  the  bony  walls  of  the  maxillary  sinus;  (G)  foreign  bodies  in 
the  maxillary  sinus;  (7)  infectious  diseases;  (8)  polj^oi;  (9)  cysts  of  the 
maxillary  sinus;  (10)  tumors. 

Etiology. — Predisposing  Causes. — Since  drainage  and  ventilation  are 
essential  to  the  health  of  a  mucus-lined  cavity,  anomalies  of  develop- 
ment in  the  form  of  the  structures  of  the  nose,  the  nasal  accessory 
sinuses  and  their  ostia,  may  predispose  to  maxillary  sinus  disease. 
Irregular,  supernumerary,  diseased,  neglected,  and  uncleanly  teeth 
and  mouths  may  also  favor  these  affections.  Conditions  of  general 
health,  age,  sex,  climate,  exposure,  habits  of  life,  and  similar  factors, 
insofar  as  they  may  tend  to  reduce  resistance  to  pathogenic  micro- 
organisms, likewise  act  as  predisposing  influences. 

Exciting  Causes. — In  a  general  way  and  approximately  in  the  order 
of  their  frequency  these  may  be  said  to  be  extension  of  disease  from 
the  nose,  mouth,  other  nasal  accessory  sinuses,  or  from  the  orbit; 
occlusion  of  the  ostium  maxillare;  infection,  either  through  the  nose, 
mouth,  or  other  accessory  sinuses,  or  through  the  circulatory  channels ; 
traumatic  injury;  cystic  formations  in  the  mucous  glands,  or  those  con- 
nected with  the  surrounding  walls;  and  rieoplasms  primarily  situated 
in  the  antrum  or  involving  it  by  invasion. 

Nasal  Etiological  Factors. — It  is  known  that  with  acute  coryza 
(acute  rhinitis)  there  may  be  extension  of  disease  to  the  maxillary 
sinus  by  continuity  of  mucous  membrane  surface,  and  infection.     As 

1  Ann.  Otol.,  Rhinol.,  and  Laryngol.,  December,  1910. 
32 


498 


DISEASES  OF  THE  MAXILLARY  SINUS 


a  result,  hA-persecretion  involves  and  engorges  the  maxillary  sinus. 
Therefore  the  causes  of  acute  rhinitis,  which  are  infinite  in  number, 
may  also  be  accounted  exciting  factors  in  the  causation  of  maxillary 
sinus  disease.  Among  these  more  particularly  might  be  noted  infec- 
tion by  the  Micrococcus  catarrhalis.  Bacillus  segmentosus,^  pneumo- 
coccus,  and  the  infections  of  influenza,  typhoid,  smallpox,  measles, 
diphtheria,  and  other  exanthematous  fevers.  Chronic  rhinitis  with 
turgescence,  hypertrophic  rhinitis,  liAperplastic  rhinitis,  and  atrophic 
rhinitis  may  result  from  factors  already  described  as  leading  to  acute 
rhinitis.     This  is  especially  true  when  there  are   deviations  of  the 


Fig.  315. — The  "vicious  circle"  of  the  nose;  b,  the  spheno- ethmoidal  fossa;  c,  the 
superior  turbinated  body;  d,  posterior  ethmoidal  cells;  e,  bulla  ethmoidalis;  /,  anterior 
ethmoidal  cells  draining  into  the  frontonasal  canal;  g,  frontal  sinus;  h,  the  ostium  of  the 
bulla  ethmoidalis;  i,  hiatus  semilunaris;  k,  the  uncinate  process  or  outer  wall  of  the 
infundibulum  or  gutter  on  the  outer  wall  of  the  nose  into  which  the  frontal,  anterior 
ethmoidal,  and  maxillary  sinuses  usually  drain.  The  high  light  below  and  anterior  to  j 
and  k  indicates  the  inferior  boundarj^  of  the  infundibulum  or  gutter  into  which  the 
sinuses  drain.  The  middle  turbinated  body  is  removed  to  exhibit  the  anatomical  details 
beneath  it.     (Ballenger.) 

septum  or  other  nasal  obstructions  which  in  the  course  of  chronic 
disease  may  cause  turgescence  of  the  "swell  bodies"  of  the  inferior 
turbinates  and  h^'perplasia  of  the  mucous  membrane  of  the  middle 
turbinal,  the  ethmoidal  cells,  and  other  structures.  Under  these  con- 
ditions there  is  usually  retention  of  secretion  by  the  close  approxima- 
tion of  the  septum  to  the  middle  turbinate,  and  the  resulting  unhealthy 
conditions  cause  this  to  act  as  an  irritant  in  passing  over  the  mucous 
membrane  of  the  middle  and  inferior  turbinate,  thus  giving  rise  to 
morbid  changes  in  these  structures.     Whether  purulent,  serous,  or 


1  Walter:  Jour.  Am.  Med.  Assn.,  p.  276. 


ORAL  ETIOLOGICAL  FACTORS  499 

mucous  in  character,  the  secretion  frequently  fills  the  maxillary  sinus 
through  the  ostium,  which  at  times  becomes  obstructed  and  results 
in  its  engorgement.  This  mucous  engorgement  of  the  maxillary 
sinus  has  by  some  authors  been  described  as  a  distinct  disease,  whereas 
it  is  properly  only  a  symptom  occurring  in  the  course  of  other  patho- 
logical conditions.  Affections  of  the  vasomotor  nervous  system  and 
general  diseases,  such  as  diabetes,  scorbutus,  rheumatism,  and  similar 
disorders,  are  quite  commonly  associated  with  both  acute  and  chronic 
disease.  Nasal  polypi  in  the  region  of  the  ostium  maxillare  not 
infrequently  cause  obstruction  and  lead  to  maxillary  sinus  disease. 

The  obstructive  lesion,  according  to  Ballenger,'^  may  be  a  deflection 
of  the  nasal  septum,  an  enlarged  or  cystic  tiirhinate,  an  enlarged  bulla 
ethmoidalis,  or  cells  in  the  uncinate  process,  the  median  wall  of  the 
infundibulum.  The  area  to  be  examined  is  shown  in  Fig.  315  within  the 
circle.  These  structures  he  has  designated  as  the  "key"  to  inflam- 
mation of  the  sinuses,  or  the  "vicious  circle"  of  the  nose. 

Nasal  operations  may  lead  to  infection  of  the  sinuses.  Injudicious 
dressings,  foreign  bodies  in  the  nose,  either  in  the  form  of  splints  or 
dressings  or  those  of  accidental  lodgment,  may  excite  irritation  by 
blocking  the  ostium  or  damming  back  the  secretions  until  they  are 
forced  into  the  sinuses  and  cause  sinuitis. 

Nasal  polypi  may  cause  obstruction  leading  to  unhealthy  con- 
ditions or  be  so  situated  as  to  obstruct  the  ostium  directly  and  thus 
cause  sinus  disease. 

Oral  Etiological  Factors. — There  has  been  and  is  at  the  present 
time  much  diversity  of  opinion  with'  regard  to  the  frequency  with 
which  diseases  of  the  teeth  and  structures  of  the  mouth  cause  antral 
disease.  The  older  writers,  if  dentists,  were  for  the  greater  part 
inclined  to  the  belief  that  empyema  of  the  maxillary  sinus  was  almost 
invariably  caused  by  diseased  teeth,  while  authors  with  practices 
limited  to  the  nose  and  its  affections  quite  universally  inclined  to  an 
almost  opposite  view.  Today,  with  a  better  general  understanding  of 
diseases  of  the  nose  and  mouth,  the  differences  of  opinion  are  less 
apparent,  but  there  should  be  even  greater  unanimity  in  this  respect. 

Tiffany^  says:  "Diseases  of  the  antrum  occur  as  a  result  of  injury, 
and  as  an  extension  from  a  diseased  tooth." 

Baer^  quotes  Brophy  as  claiming  that  at  least  85  per  cent,  of  the 
cases  of  antral  disease  are  caused  by  the  teeth.  While  very  wisely 
calling  attention  to  the  fact  that  it  would  require  the  compilation  of  a 
great  many  cases  to  prove  the  matter  one  way  or  the  other,  he  states 
that  out  of  28  cases  that  he  himself  has  treated,  25  started  primarily 
in  the  teeth,  while  3  developed  secondarily  to  primary  involvement 
of  the  frontal  sinus. 

Ballenger  states  that  the  maxillary  sinus  may  be  infected  from 

1  Diseases  of  the  Throat,  Nose,  and  Ear,  1914,  4th  Ed. 

2  American  System  of  Dentistry,  iii,  562. 

3  Dental  Cosmos,  Jxily,  1911,  p.  761. 


500  DISEASES  OF  THE  MAXILLARY  SINUS 

the  nose  or  the  teeth,  the  cases  probably  being  about  equally  divided 
between  these  two  sources  of  infection.  McCurdy^  quotes  Dmochow- 
ski,  who,  after  making  150  autopsies,  holds  that  but  few  cases  have  a 
dental  origin,  and  Fletcher,  who  examined  500  skulls,  in  252  of  which 
were  abscesses  of  the  upper  molars,  found  only  12  molars  perforating 
the  floor  of  the  antrum,  and  stated  that  he  had  never  seen  a  case  of 
antral  disease  caused  by  carious  teeth. 

^Marshall  has  expressed  the  belief  that  alveolar  abscess  is  the  most 
common  factor  in  producing  suppurative  conditions  of  the  antrum 
of  Highmore. 

These  differences  of  opinion  can  doubtless  be  explained  as  being 
chiefly  due  to  the  following  reasons: 

1.  Diseases  of  the  maxillary  sinus,  as  of  the  other  sinuses,  has 
only  recently  been  diagnosticated  in  approximate  proportion  to  its 
frequency  of  occurrence.  Therefore  many  cases  not  having  an 
external  dental  lesion  to  call  attention  to  their  existence,  and  without 
objective  nasal  symptoms  sufficiently  marked  to  lead  to  discovery, 
have  passed  unnoticed.  Under  past  methods  of  diagnosis  the  cases 
caused  by  diseased  teeth  were  more  likely  to  be  recognized,  and  thus 
the  larger  percentage  of  undiscovered  cases  would  be  of  nasal  origin. 

2.  In  the  examination  of  dried  specimens,  direct  openings  from 
the  roots  of  teeth  into  the  maxillary  sinus  were  found  to  be  common. 
It  was  therefore  argued  that  when  the  roots  of  such  teeth  bore  evi- 
dence of  abscess,  these  necessarily  caused  maxillary  sinus  disease. 
But  it  should  be  remembered  that  in  the  living  subject  the  lining 
membranes  of  the  sinus  provide  serviceable  protection  against  the 
invasion  of  pyogenic  microorganisms,  especially  when  still  further 
protected  by  the  lymph  wall  of  the  abscess  sac.  It  is  now  known 
that  such  an  abscess  may  form  at  the  root  of  the  tooth,  even  within 
the  bony  enclosure  of  the  antrum,  without  actual  infection  passing 
through  the  lining  mucous  membrane  of  the  sinus. 

In  many  cases  of  necrosis  involving  the  bony  walls,  even  when 
fractured,  the  same  membranous  protection  is  afforded.  Unless  the 
soft  tissues  within  the  sinus  are  ulcerated  or  punctured,  as  sometimes 
occurs  unnecessarily  through  injudicious  attempts  at  diagnosis  or  treat- 
ment, there  often  need  be  no  antral  disease  other  than  the  external 
lesion. 

The  author  is  convinced  that  no  satisfactory  estimate  can  be  made 
as  to  the  relative  frequency  of  oral  and  nasal  causes  of  antral  disease. 
He  believes  that  in  the  future  the  latter  will  probably  be  found  to 
outnumber  the  former  very  greatly,  owing  to  better  diagnostic  methods 
and  improved  treatment  of  the  diseased  roots  of  teeth,  and  above  all, 
perhaps,  because  of  the  prevention  of  these  by  oral  prophylaxis.  He 
has  seen  large  nmnbers  of  patients  who  suffered  for  many  years  from 
the  local  and  general  disturbances  that  were  incidental  to  maxillary 

1  Oral  Surgerj',  p.  115. 


OTHER  NASAL  ACCESSORY  SINUSES 


501 


sinus  disease  and  from  many  unnecessarily  ineffective  operations  that 
might  have  been  a\'oided  had  there  been  early  recognition  of  quite 
simple  and  to  the  trained  observer  perfectly  obvious  diseases  of  the 
teeth  and  moutli,  and  for  this  reason  he  has  no  desire  to  underestimate 
the  actual  importance  of  careful  study  of  and  constant  watchfulness 
for  factors  of  this  natvu'e  in  diagnosis. 

Other  Nasal  Accessory  Sinuses.— Diseases  of  the  antrvmi  of  High- 
more  may  result  from  primary  pathological  conditions  of  the  frontal, 
ethmoidal,  or  sphenoidal  sinuses  and  cells,  and  these  in  turn  are 
likewise  affected  secondarily  from  the  maxillary  sinus.  Figs.  31G,  317 
and  318  are  illustrations  of  conditions  favorable  to  such  extension  of 
disease.  The  decision  as  to  which  one  of  the  accessory  sinuses  most 
often  communicates  infection  to  the  others  necessarily  depends  upon 
the  identification  of  \he  one  most  frequently  diseased. 


Fig.  316. — Anterior  view  of  vertical  transverse  section  in  the  region  of  the  first  molar 
teeth,  showing  anterior  ethmoidal  cells  and  a  cell  in  the  crista  galli.  The  frontal  sinus 
extends  downward,  becoming  common  with  the  ethmoidal  cells  and  antrum.  (After 
Cryer.) 


Ballenger  states  that  the  maxillary  sinus  is  perhaps  more  often 
affected  singly  than  any  of  the  other  sinuses,  because  in  about  one- 
half  of  the  cases  it  is  infected  from  the  teeth  rather  than  from  the 
nose,  whereas  the  other  sinuses  are  nearly  always  infected  from  the 
nose.  Having  a  common  source  of  infection,  they  are  therefore  more 
often  simultaneously  diseased. 

He  also  claims  that  knowledge  of  the  diseases  of  the  sinuses  :n 
general  has  so  greatly  increased  during  the  last  few  years  that  eth- 
moidal, sphenoidal,  and  frontal  sinus  affections  are  diagnosticated 
twenty  times  as  often  as  they  used  to  be.  The  author  is  convinced 
that  in  the  near  future  the  importance  of  these  diseases  from  a  patho- 


502 


DISEASES  OF  THE  MAXILLARY  SINUS 


logical  point  of  view  will  be  greatly  increased,  and  they  will  be  recog- 
nized much  more  frequently  than  at  present. 


Infra-orbital    sinus 
Infra-orbital   canal 


Hiatus 

semilunaris 


Fig.  317. — View  of  a  vertical  transverse  section  through  the  first  molar  teeth.  The 
right  hiatus  semilunaris  in  this  subject  communicates  with  the  maxillary  sinus  without 
a  true  ostium  maxillare.      (After  Cryer.) 


Fig.  318. — -Anterior  and  posterior  views  of  a  vertical  transverse  section  in  the  region 
between  the  second  premolar  and  first  molar  teeth,  showing  a  wire  passing  from  the 
frontal  sinus  into  the  maxillary  sinus.  The  frontal  sinus  extended  downward  to  nearly 
the  level  of  the  upper  portion  of  the  antrum.     (After  Cryer.) 


OTHER  NASAL  ACCESSORY  SINUSES  503 

J.  P.  Tunis/  ill  his  report  on  inflammations  of  the  maxillary  sinus 
with  special  reference  to  empyema,  based  upon  the  study  of  100 
unselected  heads  examined  a  few  hours  after  death  in  the  autopsy 
room  of  the  Vienna  General  Hospital,  gives  the  following  conclusions: 

"1.  In  the  examination  of  100  heads  in  the  autopsy  room,  37  per 
cent,  showed  some  evidence  of  pathological  changes  in  the  maxillary 
antra. 

"2.  Of  these  37  cases,  11  were  examples  of  edema,  12  were  examples 
of  chronic  inflammation  of  empyema,  1  was  an  example  of  an  alveolar 
or  dental  cyst,  and  13  were  examples  of  retention  cyst. 

"3.  With  one  or  two  exceptions  all  of  these  cases  were  undiag- 
nosticated  during  life. 

"4.  The  presence  of  a  large  amount  of  pus  in  10  out  of  12  of  these 
cases  of  empyema  may  have  played  an  active  part  in  causing  the 
death  of  the  patients." 

Schaefi^er^  says:  "Of  the  specimens"  (ninety)  "studied  to  ascertain 
the  frontomaxillary  relations,  56  per  cent,  showed  that  the  infundib- 
ulum  ethmoidale  was  intimately  related  with  the  nasofrontal  duct, 
or  with  the  sinus  frontalis  directly  in  case  the  nasofrontal  duct  was 
wanting;  40  per  cent,  showed  that  the  nasofrontal  duct  directly  com- 
municates with  the  meatus  nasi  medius,  the  infundibulum  ethmoidale 
ending  blindly  or  in  air  cells;  2.5  per  cent,  showed  two  nasofrontal 
ducts,  one  continuous  with  the  infundibulum  ethmoidale,  and  the 
other  communicating  with  the  meatus  nasi  medius;  1.25  per  cent, 
showed  a  direct  communication  between  the  sinus  frontalis  and  maxil- 
laris. 

"Since  the  infundibulum  ethmoidale  receives  the  ostium  maxillare 
at  its  dorsal  and  inferior  end  in  all  cases,  and  the  nasofrontal  duct, 
or  the  sinus  frontalis  directly,  at  its  ventral  and  superior  end  in  over 
one-half  the  cases,  it  frequently  serves  as  a  gutter-like  channel,  of 
varying  depth  and  efficiency,  communicating  between  the  frontal 
region  and  the  sinus  maxillaris. 

"The  sinus  maxillaris  therefore  acts  as  a  reservoir  for  fluids  coming 
to  the  dorsal  end  of  the  infundibulum  ethmoidale  (the  ostium  maxillare 
being  patent) . 

"Frequently  the  processus  uncinatus  by  a  superior  curving  at 
its  dorsal  end  causes  the  infundibulimi  ethmoidale  to  end  in  a  pocket. 
This  pocket  is  so  situated  that  it  directs  fluids  coming  to  the  dorsal 
end  of  the  infundibulum  ethmoidale  mto  the  sinus  maxillaris  via  the 
ostium  maxillare,  which  is  in  the  immediate  vicinity. 

"Occasionally  branches  of  the  superior  alveolar  nerves  in  passing 
to  the  superior  dental  plexus  pass  entirely  through  the  walls  of  the 
sinus,  thence  under  cover  of  the  mucous  membrane  of  the  cavity  to 
their  destination.  Rarely  the  anterosuperior  alveolar  ramus,  instead 
of  taking  its  usual  course,  passes  diagonally  from  the  roof  of  the  sinus 

1  Laryngoscope,  October,  1910. 

'^  Ann.  Otol.,  Rhinol.,  and  Laryngol.,  December,  1910. 


504  DISEASES  OF  THE  MAXILLARY  SINUS 

to  its  ventral  wall — the  nerve  thus  suspended  freely  in  the  cavity  is 
merely  covered  with  the  mucous  membrane." 

Dr.  Walter  V.  Brem,  of  Los  Angeles,  formerly  of  the  Colon  Hospital, 
Cristobal,  Canal  Zone,  has  given  the  author  a  most  interesting  record 
of  his  postmortem  examinations  of  the  accessory  sinuses  while  acting 
pathologist  at  the  Ancon  Hospital.  The  sphenoidal,  frontal,  and 
maxillary  sinuses  were  examined  in  about  300  bodies  of  patients  who 
died  of  various  diseases.  Of  these,  about  140  deaths  were  due  to 
pneumococcus  infections.  All  cases  of  Pneumococcus  meningitis 
showed  purulent  inflammation  of  one  or  more  of  the  nasal  accessory 
sinuses.  About  70  per  cent,  of  the  pneiunonia  cases  showed  the  same 
thing.  Purulent  involvement  was  found  not  infrequently  in  other 
cases,  and  chronic  and  subacute  inflammations  in  about  40  per  cent. 
In  approximately  14  per  cent,  of  the  non-pneumococcic  deaths,  pneu- 
mococci  were  present  in  one  or  more  of  the  sinuses.  Cocci  and  uni- 
dentified bacilli  were  frequently  present.  In  many  of  these  sinuses 
the  lining  membranes  were  thickened,  and  moist  and  stained  smears 
showed  pus  cells  and  bacteria. 

Circulatory  Chanrels. — Diseases  of  the  blood  and  infections  carried 
through  the  circulation  may  affect  the  maxillary  sinus  in  the  same 
manner  as  the  other  anatomical  parts.  The  character  of  the  lesion 
would  necessarily  depend  upon  the  nature  of  the  infection. 

Traumatism. — ^Traumatism  through  injury  to  external  structures 
may  excite  inflammatory  conditions,  which  in  the  course  of  their 
progress  sometimes  involve  the  antrum,  or  fracture  of  the  bony  walls 
may  open  the  way  for  infection.  It  has  been  usual  m  the  author's 
experience  to  find  that  fractures  of  the  superior  maxilla,  including  the 
walls  of  the  maxillary  sinus,  even  though  there  may  be  considerable 
discharge  of  pus,  rarely  cause  continued  empyema.  In  most  cases 
the  lining  membranes  of  the  sinus  protect  it  against  direct  infection 
if  these  are  not  lacerated,  and  even  when  infection  has  occurred  and 
an  acute  empyema  has  resulted,  the  symptoms  quickly  subsided  after 
the  fracture  was  united. 

Symptoms. — Acute  Catarrhal  Sinuitis. — Pain. — In  this  form  of  sinus 
disease  there  is  a  sense  of  fulness  on  the  affected  side,  or  pain  which 
is  sometimes  manifested  in  the  form  of  a  dull  headache,  although 
occasionally  it  is  more  severe  and  quite  generally  distributed  over 
the  frontal,  occipital,  and  facial  regions.  It  may  be  acute,  distinctly 
infra-orbital  or  supra-orbital,  or  be  chiefly  confined  to  the  eyeball 
through  pressure  from  beneath  the  floor  of  the  orbit. 

Discharge. — ^The  nasal  discharge  in  acute  rhinitis,  which  usually 
accompanies  this  class  of  cases,  is  often  so  active  as  to  prevent  the 
sinus  discharge  from  being  recognized  as  a  distinct  diagnostic  feature. 

Chronic  Catarrhal  Maxillary  Sinuitis. —  Discharge.- — These  cases  usu- 
ally give  history  of  previous  acute  catarrhal  attacks.  The  buccal 
and  palatal  walls  of  the  sinus  are  almost  invariably  thin,  and  yield 
to  pressure  on  account  of  enlargement  of  the  sinus  through  being  filled 


CHRONIC  SUPPURATIVE  SI  NU  IT  IS  505 

with  fluid  and  long  continuation  of  disease  affecting  the  bony  walls. 
Unilateral  discharge  is  usually  a  more  or  less  constant  symptom,  and 
when  not  sufficiently  marked,  intranasal  examination  will  almost 
invariably  disclose  that  the  naris  on  the  affected  side  gives  evidence 
of  some  form  of  chronic  rhinitis.  Usually  tissues  surrounding  the 
ostium  appear  diseased,  and  occasionally  polypi  within  the  maxillarv^ 
sinus  may  be  diagnosticated  through  the  ostimn  by  intranasal  exami- 
nation, ^lore  often  polypi  limited  to  the  nasal  meatus  are  present, 
although  this  is  not  pathognomonic  of  antrimi  suppuration,  as  was 
formerly  supposed. 

Pain. — Pain  in  these  cases  is  usually  not  severe,  may  be  entirely 
absent,  or  may  appear  and  disappear  from  time  to  time  as  repeated 
engorgements  of  the  sinus  occur,  or  there  may  be  distinct  involvement 
of  the  fifth  nerve,  ^specially  the  infra-orbital  division  which  passes 
across  the  walls  of  the  sinus  and  in  many  cases  lies  con>pletely  within 
the  bony  encasement,  protected  only  by  the  lining  membranes,  and 
therefore  easily  subject  to  pressure  from  fiuid  or  the  direct  influence 
of  continued  inflammatory  conditions.  Chronic  neuralgia,  sometimes 
in  the  form  of  tic  douloureux,  is  frequently  associated  with  these  cases. 

Acute  Suppurative  Sinuitis. — The  symptoms  of  acute  empyema  are 
much  like  those  of  acute  catarrhal  conditions,  except  that  o^dng  to 
the  presence  of  pus  and  formation  of  gases,  the  SATnptoms  are  likely 
to  be  in  all  respects  more  severe,  both  pain  and  pressure  being,  as  a 
rule,  quite  marked.  The  unilateral  discharge  is  more  often  a  promi- 
nent feature,  and  the  dripping  of  the  foul  secretions  into  the  pharynx 
is  a  noticeable  and  disagreeable  s^Tnptom. 

Chronic  Suppurative  Sinuitis. — Discharge. — Unilateral  discharge  is  a 
characteristic  s\niptom  of  these  cases,  but  is  not  always  a  depend- 
able indication,  because  infection  may  extend  to  the  opposite  sinus, 
and  with  the  maxillary  antra  on  both  sides  diseased,  the  discharge 
would  probably  be  bilateral. 

Pain. — Pain  may  be  entirely  absent  except  during  occasional 
acute  attacks,  or  may  be  of  general  character;  it  may  be  distributed 
through  the  various  divisions  of  the  fifth  nerve  on  the  affected  side 
or  confined  to  one  of  them;  and  it  may  appear  to  be  directly  connected 
with  the  affected  sinus,  or  reflected  to  some  more  remote  division. 
There  may  be  tenderness  to  pressure  in  the  region  of  the  infra-orbital 
or  the  supra-orbital  foramina,  or  both.  Slight  or  severe  pain  may  be 
felt  in  the  eye  or  may  be  entirely  absent,  or  only  sufficient  to  produce 
a  stiffness  in  movement,  or  the  floor  of  the  orbit  may  be  forced  upward 
by  pressure  sufficiently  to  excite  pain  in  the  eyeball  and  cause  it  to 
be  so  compressed  as  to  have  the  appearance  of  glaucoma. 

Other  Symptoms. — The  bony  walls  of  the  antrimi  may  be  bulged 
outward  and  cause  noticeable  swelling  on  the  affected  side,  or  there 
may  be  no  outward  sign  of  the  disease  other  than  the  thinness  of  the 
external  wall,  which  causes  it  to  yield  to  pressure  with  a  more  or  less 
crepitant  sound.     Examination  of  the  ostimn   usually  discloses  dis- 


506  DISEASES  OF  THE  MAXILLARY  SINUS 

charge  of  pus,  which,  if  wiped  away,  appears  again.  By  packing  the 
ostia  of  the  other  sinuses  and  applying  suction,  the  pus  from  within 
the  maxillary  sinus  can  be  brought  into  view.  In  many  of  these  cases 
there  is  a  history  of  awakening  in  the  morning  with  a  foul  mass  of 
secretion  in  the  pharynx,  an  unpleasant  odor  which  disappears  during 
the  day,  and  a  sense  of  fulness  or  even  pain  which  is  relieved  by  lying 
with  the  face  turned  upon  the  opposite  side. 

Differential  Diagnosis. — The  clinical  aspect  of  maxillary  sinus 
disease  so  seldom  presents  a  tj^jical  series  of  sjonptoms  that  it  is 
frequently  necessary  to  make  diagnosis  from  some  one  or  more  of 
the  indications  which  lead  to  suspicion  of  the  existence  of  the  affec- 
tion. Under  these  circumstances  it  is  important  that  a  number  of 
diagnostic  aids  should  be  employed  in  order  that  a  correct  diagnosis 
may  result. 

Nasal  Discharge. — In  acute  maxillary  sinuitis  the  unusual  secretion 
and  other  symptoms  which  accompany  ozena  are  unmistakable. 
Quite  frequently  upon  stooping  or  turning  the  head  upon  one  side  there 
is  a  momentary  gush  of  fluid  from  the  nose.  In  chronic  cases  the 
only  indication  of  unilateral  discharge  may  be  an  unhealthy  appear- 
ance at  the  external  opening  of  the  naris  on  the  affected  side,  or  the 
patient  may  admit  being  barely  conscious  of  freer  discharge  from  one 
naris  than  the  other.  There  may  or  may  not  be  a  foul  odor  from  the 
nasal  secretion  or  from  the  patient's  breath;  on  the  other  hand,  con- 
stant dropping  of  foul  secretion  from  the  nasopharynx  is  sometimes 
a  distinguishing  feature,  or  this  may  only  be  noticed  upon  waking  in 
the  morning.  In  marked  cases  the  unilateral  nasal  discharge  is  quite 
evident.  A  sense  of  fulness  and  discomfort  when  the  patient  lies  with 
the  head  turned  upon  the  affected  side,  which  is  correspondingly 
relieved  by  lying  upon  the  opposite  side,  or  cessation  of  the  discharge 
when  lying  upon  the  back,  are  symptoms  of  importance.  The  pres- 
ence of  diseased  secretion  in  the  maxillary  antrum,  when  not  other- 
wise demonstrable,  may  be  tested  by  suction  applied  at  the  ostium 
maxillare  to  draw  out  the  fluid  and  allow  its  nature  to  be  determined. 
In  difterential  diagnosis  to  decide  whether  the  case  is  one  of  simple 
empyema  (confined  to  one  sinus)  or  whether  the  discharge  comes 
from  the  maxillary  or  some  other  sinus,  pack  the  region  of  the  ostia 
of  all  the  sinuses  except  the  maxillary  and  then  apply  suction.  In 
open  empyema  (with  the  ostium  open)  these  tests  will  be  efficient, 
and  in  closed  empyema  (with  the  ostium  closed)  the  result  will  be 
negative. 

In  latent  empyema,  a  case  in  which  the  ostium  is  not  fully  closed 
and  not  completely  open,  secretion  may  be  drawn  from  the  sinus, 
but  not  as  freely  as  in  open  empyema  cases. 

Intranasal  Examination. — Internal  examination  of  the  nose  will 
sometimes  show  an  appearance  of  ulceration  or  other  disease  of  the 
mucous  membrane  in  the  region  of  the  ostium.  This  indicates  that 
it  is  more  or  less  constantly  bathed  with  vicious  fluids,  even  though 


TEETH  IN  DISEASES  OF  THE  MAXILLARY  SINUS  507 

this  may  not  be  apparent  through  an  external  discharge  and  may 
not  at  the  moment  be  otherwise  demonstrable.  It  must  be  remem- 
bered that  in  chronic  antral  disease  there  is  great  difference  in  the 
quantity  and  nature  of  the  secretions  at  different  times.  An  ordinary 
open  ostiiun  may  for  the  time  being  be  closed  by  inflammatory  pro- 
cesses affecting  the  surrounding  mucous  membrane,  or  be  occluded  by 
a  polj^us  or  some  other  obstruction,  and  thus  in  effect  be  the  same 
as  closed  empyema.  The  inner  wall  of  the  antrum  is  sometimes  forced 
toward  the  septmn. 

Pain. — In  acute  cases,  whether  the  fluid  be  pus  or  other  secretion, 
the  pain  sometimes  is  intense  owing  to  pressure  upon  the  nerve  as 
previously  described.  In  chronic  empyema  the  same  condition  may 
occur  during  acute  attacks,  or  for  the  same  reasons  there  may  be 
periods  during  which  pain  may  be  distributed  over  the  entire  side  of 
the  face  and  extend  to  the  frontal,  temporal,  and  occipital  regions. 
As  the  engorgement  of  the  antriun  becomes  relieved,  this  pain  gradu- 
ally subsides.  These  cases  are  frequently  mistaken  for  periodic 
migrainoid  headaches  until  the  antrum  disease  is  discovered  by  other 
diagnostic  indications.  Pressure  over  the  malar  bone  or  the  infra- 
orbital or  the  supra-orbital  foramina  may  elicit  tenderness.  A  more 
or  less  considerable  skin  surface  may  be  so  h;y^eresthetic  as  to  be 
sensitive  to  the  slightest  touch.  Supra-orbital  or  infra-orbital  neu- 
ralgia or  pain  reflected  to  other  divisions  of  the  fifth  nerve  or  tic 
douloureux  may  be  manifest  with  maxillary  sinus  diseases.  None  of 
these  may  be  considered  pathognomonic,  because  many  other  sources 
of  irritation  give  rise  to  similar  symptoms,  but  taken  with  other  cor- 
roborative diagnostic  signs  their  significance  is  valuable. 

In  rare  cases  the  sinus  may  be  so  greatly  enlarged  as  to  cause  a 
bulging  outward  of  the  cheek  upon  the  affected  side  until  it  appears 
to  be  swollen,  but  unless  the  infection  finds  its  way  through  the  walls 
of  the  sinus  into  the  overlying  soft  tissues  there  is  no  actual  swelling 
of  these  structures.  Much  more  frequently  the  buccal  wall  is  suffi- 
ciently enlarged  and  forced  outward  to  be  easily  recognized  in  oral 
examination.  Pressure  with  the  finger  along  this  wall  usually  dis- 
closes one  or  more  points  at  which  the  bone  is  exceedingly  thin  and 
yielding,  often  with  a  crepitant  sound  upon  pressure,  especially  when 
there  has  been  a  long-continued  necrotic  condition  of  the  sinus. 

The  palatal  wall  in  chronic  cases  is  generally  thin  and  yielding, 
and  not  infrequently  bulged  out  of  form  through  enlargement  of  the 
sinus. 

Teeth. — ^The  teeth  upon  the  suspected  side  should  receive  an  exceed- 
ingly careful  examination.  If  diseased  roots  of  teeth  are  present 
they  must  be  tested  to  determine  whether  they  may  not  have  been 
the  first  cause  of  the  antral  disease.  The  socket  of  any  diseased  root 
that  it  may  be  necessary  to  extract  should  be  disinfected  and  a  probe 
forced  gently  upward  to  the  end  of  the  alveolus,  to  determine  whether 
it  actually  enters  the  sinus  cavity.     Great  care  should  be  exercised 


508  DISEASES  OF  THE  MAXILLARY  SINUS 

to  avoid  forcing  the  probe  upward  in  such  a  manner  as  to  carry  infec- 
tion that  might  not  otherwise  reach  it  directly  into  the  sinus. 

When  there  is  no  evidence  of  dental  caries  or  dento-alveolar  abscess, 
teeth  with  filhngs  should  be  tested  with  hot  gutta-percha,  hot  instru- 
ments, or  ice.  The  light  reflected  from  an  electric  mouth  lamp  should 
be  employed  to  ascertain  the  condition  of  the  tooth  pulps.  If  the 
tooth  crowns  are  dark  and  it  is  evident  that  the  pulps  have  been 
devitalized  in  the  course  of  treatment  or  through  some  pathological 
process,  the  question  as  to  the  proper  filling  of  the  roots  must  be 
determined. 

The  absence  of  a  normal  tooth  from  the  jaw  upon  the  affected  or 
suspected  side  must  be  accounted  for  either  by  history  of  previous 
extraction  or  its  position  if  unerupted  must  be  definitely  determined. 
The  presence  or  absence  of  supernumerary  teeth  must  also  be  con- 
sidered and  tested.  Interstitial  gingivitis,  ulcerative  or  other  forms 
of  stomatitis,  will  be  readily  recognized,  and  with  a  probe  the  passage- 
way for  infection  located. 

Transillumination. — The  patient  is  placed  in  a  dark  room  and  the 
lips  are  tightly  closed  around  an  electric  light  held  in  the  mouth. 
When  the  appearance  is  as  shown  in  Plate  XVIII,  and  there  is  opacity 
over  the  lower  eyelid,  a  non-luminous  pupil,  absence  of  sense  of  light 
when  the  eye  is  closed,  and  a  darkened  area  outlining  the  antrum  on 
the  affected  side,  the  indications  would  point  to  empyema  of  the 
maxillary  sinus.  The  difficulty,  however,  with  this  method  of  diag- 
nosis lies  in  the  fact  that  maxillary  antra  sometimes  vary  so  greatly 
in  the  size  and  thickness  of  their  walls  in  the  same  individual.  The 
author  has  repeatedly  noted  marked  opacity  upon  one  side  in  the 
region  of  the  maxillary  sinus  in  comparison  with  the  opposite  one,  even 
when  both  antra  were  normal. 

Ballenger,  who  recognizes  the  uncertainty  due  to  anatomical  differ- 
ences, says  the  three  points  to  be  noted  in  transillumination  are:  (1) 
The  red  pupillary  reflex;  (2)  the  crescent  of  light  corresponding  to 
the  position  of  the  lower  eyelid;  and  (3)  the  sense  of  light  in  the  eye 
when  closed.  If  the  red  pupillary  reflex  and  the  crescent  of  light 
are  absent  the  antrum  is  probably  affected.  By  noting  both  sides 
at  once  it  may  be  determined  which  side,  if  either,  of  the  maxillary 
sinuses  is  affected. 

Radiographs. — The  use  of  the  a:-rays  is  undeniably  valuable  in  these 
cases.  It  is  the  most  reliable  method  of  determining  the  etiological 
relation  of  teeth  and  roots  in  many  respects  that  otherwise  might  be 
exceedingly  difficult  or  impossible  to  distinguish.  Root  fillings  that 
have  been  imperfectly  inserted,  crowns  attached  with  pins  that  project 
through  the  sides  of  the  roots,  extensive  dento-alveolar  abscesses,  and 
the  acute  penetration  of  roots  into  the  antrum,  as  well  as  the  presence 
and  situation  of  impacted  teeth,  may  be  causes  of  maxillary  sinus 
disease  or  the  presence  of  such  teeth  within  the  maxillary  sinus  itself. 

Fractures  and  diseased  conditions  of  the  antral  walls  that  might 


PLATE    XVIII 


Right  Lett 

Transillumination  of  the  Antra.     (Coakley.) 

Right,  healthy  ;   left  diseased. 


PROPHYLAXIS  OF  THE  MAXILLARY  SINUS  509 

Otherwise  escape  notice  are  also  shown  by  this  aid.  How  far  the 
average  radiograph  may  be  trusted  in  portrayal  of  the  disease  itself 
is  a  matter  of  grave  question.  Sometimes,  undoubtedly,  empyema  is 
plainly  discernible  in  this  way;  but  it  is  not  safe  to  be  too  positive  in 
regard  to  this  evidence  witliout  confirmation  from  some  other  indi- 
cation. 


Fig.  Sl'J. — Radiograph  sho'n-ing  left  maxillarj- sinus  cloudy  when  compared  with  the 
opposite  antrum,  an  indication  that  it  is  full  of  pus. 

Puncture. — Pmicture  of  the  maxillary  sinus  through  the  inferior 
meatus  to.  permit  the  withdrawal  of  its  contents  by  suction,  aspira- 
tion, or  washing  out  through  the  ostium  is  one  of  the  final  methods  of 
determming  the  actual  state  of  the  sinus.  Pimcture  with  a  trocar 
and  cannula  through  the  anterior  wall  gives  the  same  result,  and  if 
carefully  done  is  not  likely  to  cause  infection,  but  carelessly  done, 
a  pre^^ously  healthy  sinus  might  be  infected. 

Prophylaxis  of  the  Maxillary  Sinus. — Study  of  sections  of  the  heads 
of  embryos  shows  that  from  the  fourth  month  of  embryonic  life 
when  development  of  the  maxillary  sinus  takes  place  by  invagination 
of  the  lining  membrane  of  the  nose  from  the  hiatus  semilunaris,  until 
buth,  certam  marked  changes  take  place.  All  of  these  are  subject  to 
developing  dental  organs,  and  after  birth  this  same  developmental 
dependency  continues  throughout  the  period  of  growth. 


510  DISEASES  OF  THE  MAXILLARY  SINUS 

With  these  principles  rightly  comprehended,  it  must  be  apparent 
that  in  the  course  of  the  development  which  precedes  the  eruption 
of  the  permanent  teeth,  and  after^vard  during  their  existence,  oral 
hygiene,  oral  and  dental  prophylaxis,  the  care  of  children's  teeth,  and 
above  all  prompt  attention  to  the  early  expansion  of  dental  arches 
(described  on  pp.  550  and  551),  are  measures  of  vital  importance  in 
endeavoring  to  avoid  pathological  states  of  the  maxillary  and  acces- 
sory sinuses. 

Laying  aside  for  the  moment  all  corroborative  knowledge  gained 
through  unlimited  and  undisputed  clinical  evidence  of  the  frequency 
of  pathological  conditions  of  the  nasal  accessory  sinuses  in  individuals 
who  have  any  of  the  associated  nasal,  palatal,  or  maxillary  malfor- 
mations, the  result  of  restricted  maxillary  growth  upon  the  nose,  as 
sho\ra  in  the  groups  of  sections  of  dogs'  heads  (p.  566),  is  alone  suffi- 
cient to  banish  every  doubt  of  the  great  advantage  as  a  preventive 
measure  of  giving  free  and  unrestricted  growth  to  all  this  region,  by 
prompt  and  efficient  separation  of  the  maxilh*. 

Similarly,  any  abnormal  tendency  evidenced  in  the  nose  and  throat 
should  receive  treatment.  The  removal  of  adenoids,  of  enlarged 
tonsils,  and  the  correction  of  h;y-pertrophic  or  other  intranasal  con- 
ditions that  predispose  to  disease  are  demanded  quite  as  much  for 
the  prevention  of  future  sinus  disease  as  for  the  immediate  remedial 
efl'ect  upon  the  nasal  condition. 

Surgical  Treatment  of  the  MaxiUary  Sinus.— The  following  opera- 
tions are  the  ones  usually  employed:  (1)  Alveolar,  (2)  palatal,  (3) 
intranasal,  (4)  Kuster,  (5)  Caldwell-Luc,  (6)  Denker,  and  (7)  Caniield- 
Ballenger. 

Alveolar  Operation. — ^The  alveolar  operation,  sometimes  called  the 
Cooper  operation,  has  been  extensively  practised  in  this  and  other 
countries.  In  this  method  a  tooth  or  root  was  extracted  and  its  socket 
enlarged  and  elongated  until  an  opening  into  the  antrum  was  effected. 
In  edentulous  jaws  an  opening  was  made  through  the  alveolar  ridge 
of  the  mouth  into  the  sums.  Irrigation  and  drainage  through  this 
opening  were  supplemented  by  the  use  of  drainage  tubes  of  rubber 
or  metal,  which  were  kept  in  place  by  attachment  to  teeth  or  to  plates 
resting  on  the  surface  of  the  jaws. 

It  seemed  a  most  radical  and  effective  surgical  procedure  after 
the  earlier  and  still  less  effective  plan  of  treatment  by  irrigation 
through  the  root  canal  of  a  tooth,  which  most  dentists  formerly 
employed. 

Large  numbers  of  cases  of  antral  empyema  have  been  successfully 
treated  by  the  alveolar  method,  but  other  operations  are  to  be  pre- 
ferred, principally  for  the  following  reasons:  (1)  It  is  not  always 
necessary  to  sacrifice  a  tooth  because  the  maxillary  sinus  is  diseased. 
No  tooth  should  be  lost  that  a  skilful  dentist  can  make  useful  and 
cure  with  sufficient  certainty  to  remove  danger  of  future  infection 
from  this  source.     (2)  The  thickness  of  bone  structure  between  the 


INTRANASAL  OPERATION  611 

apical  end  of  the  alveolus  of  the  extracted  tooth  root  and  the  sinus 
is  usually  greater  than  one  unaccustomed  to  the  operation  would 
expect.  Raw  surface  is  thus  exposed  to  infection,  and  more  pain 
caused  in  packing  or  irrigation  than  is  necessary  for  even  more  radical 
operations.  (3)  In  many  cases  it  is  impossible  to  gain  complete 
access  to  all  parts  of  the  sinus  through  openings  of  this  kind  and  of 
the  size  usually  recommended.  (4)  No  drainage  tube  can  be  inserted 
with  certainty  of  giving  complete  drainage  for  a  sufficient  length  of 
time  to  be  effective.  Those  worn,  as  many  were,  for  periods  of  ten, 
fifteen  or  twenty  years,  simply  served  to  prevent  acute  attacks  and 
also  as  effectively  prevented  the  possibility  of  cure. 

It  is  frequently  advisable  to  extract,  one  or  more  diseased  teeth 
when  these  are  etiological  factors  or  a  menace  to  the  future  health 
of  the  sinus.  In  such  cases  the  socket  should  be  reamed  out  and  the 
opening  enlarged,  but  the  regular  operation  for  radical  treatment 
must  be  performed  without  reference  to  the  alveolar  opening,  except 
that  by  extending  it  to  the  tooth  socket  the  fullest  possibility  of 
access  and  drainage  is  secured. 

Palatal  Entrance. — Treatment  through  an  opening  in  the  palatal 
wall  may  sometunes  be  necessary  when  pus  has  already  found  an 
exit  in  that  direction  and  a  large  portion  of  this  bone  surface  has 
been  destroyed.  Those  who  are  familiar  with  the  difficulty  of  keep- 
ing the  antrum  clean  during  the  very  slow  progress  of  closure  of  an 
opening  in  this  situation  are  not  likely  to  adopt  it  as  a  regular  pro- 
cedure when  once  cognizant  of  the  advantages  of  other  methods. 
When  this  is  done,  however,  it  is  possible  to  curette  and  pack  the 
sinus  quite  satisfactorily. 

Intranasal  Operation. — Puncture  of  the  naso-antral  wall  and  irri- 
gation through  a  cannula  are  sometimes  all  that  is  necessary  for  the 
cure  of  acute  inflammatory  conditions  of  a  maxillary  sinus,  especially 
when  there  is  no  history  of  similar  attacks.  The  trocar  and  cannula 
may  be  passed  through  the  naso-antral  wall  at  the  inferior  meatus 
or  the  anterior  wall  at  the  canme  fossa.  The  naso-antral  entrance 
is  preferable  because  it  offers  less  opportunity  for  infection.  A  can- 
nula can  be  passed  into  the  antrum  almost  as  easily  at  this  point  as 
through  the  oro-antral  wall  at  the  canine  fossa.  If  carefully  done, 
however,  puncture  through  the  thinnest  portion  of  the  anterior  wall 
offers  an  exceedingly  direct  and  simple  method  of  entrance;  with 
proper  antiseptic  precaution  the  danger  of  infection  need  not  be 
seriously  considered. 

When  the  trocar  is  withdrawn,  a  rubber  tube  is  attached  to  the 
cannula,  and  through  this  irrigation  with  normal  salt  solution  is  con- 
tinued until  the  fluid  as  it  passes  from  the  nose  becomes  clear  and 
inoffensive.  When  the  ostium  is  closed,  whether  it  be  due  to  abnormal 
development,  temporary' obstruction  by  inflammatory  processes,  polypi, 
or  crusts,  this  method  will  not  be  successful,  because  the  fluid  will 
simply  serve  to  increase  the  engorgement  of  the  antrum  and  be  likely 


512 


DISEASES  OF  THE  MAXILLARY  SINUS 


to  cause  more  or  less  pain  through  increased  pressure.  In  such  cases, 
unless  the  opening  through  the  ostium  can  be  reestablished,  it  will  be 
necessary  to  make  a  second  opening  or  to  enlarge  the  one  already  made 
sufficiently  to  afford  all  fluids  free  exit. 

Removal  of  the  Naso-antral  Wall. — In  the  performance  of  this  opera- 
tion a  large  opening  is  made  through  the  naso-antral  wall.  Experience 
has  proved  that  small  openings  from  the  nose  into  the  maxillary  sinus 
\nll  close,  but  that  a  large  opening  will  remain  permanently  open. 

Local  anesthesia  and  freedom  from  hemorrhage  are  secured  by 
applications  of  coca  in  and  adrenalin  solution  to  the  inferior  turbinal 
and  the  inferior  and  middle  meatus.  The  anterior  half  of  the  inferior 
turbinate  body  is  removed  with  a  knife,  scissors,  saw,  or  other  suitable 
instrument.  Baer  dislocates  the  inferior  turbinate  upward,  and  after 
the  operation  is  performed  replaces  it.  He  claims  this  is  a  material 
advantage  because  function  is  not  so  much  impaired  in  this  way  as 
when  a  portion  of  the  inferior  turbinate  is  removed.  With  the  inferior 
turbinate  out  of  the  way  the  naso-antral  wall  is  punctured  and  a  large 
portion  of  its  surface  removed.  There  are  many  ingeniously  devised 
instruments  for  this  purpose,  as,  for  example,  Vail's  antrum  saws, 
Corwin's  antnun  chisels,  different  forms  of  trephines  and  forceps,  such 
as  the  Nobel-Cordes  forceps  (Fig.  320). 


Fig.  320. — Remo\-ing  the  naso-antral  wall  with  the  Xobel-Cordes  forceps.      (Ballenger.) 

Stein^  uses  his  own  notched  gouge  chisels  (Fig.  321)  for  this  purpose. 
He  describes  his  method  of  performing  the  operation  as  follows: 

"  If  a  large  opening  into  the  antrum  is  desired  one  of  two  procedures 
may  be  followed:  (1)  For  an  opening  with  the  removal  of  part  or  all 
of  the  lower  turbinate.     Enter  one  point  of  the  ^'  with  the  concavity 


Larj'ngoscope,  St.  Louis,  February,  1910 


THE  KUSTER  OPERATIOX  513 

of  the  instrument  directed  toward  the  floor  of  the  nose,  just  within 
the  pyriforni  process  of  the  antral  wall,  driving  backward  and  outward 
until  the  sliarp  point  perforates  into  the  antrum  ca\'ity,  then,  with  the 
instrument  still  in  situ,  depress  the  handle  and  push  backward;  this 
gives  a  gentle  upward  ciu-ve  through  the  thin  bone  of  the  middle  meatus 
region,  one  blade  of  the  V  being  m  the  antrum  and  the  other  in  the 
middle  meatus.  As  you  progress  backward  gradually  elevate  the  handle 
so  as  to  direct  the  cutting  \'  downward  in  the  direction  of  the  lower 
turbinate  again,  passing  through  it  at  any  part  the  operator  may  select. 
Remove  the  instrument  and  reenter  at  the  point  of  first  incision,  but 
with  the  handle  elevated  and  the  concavity  directed  upward,  thus  forc- 
ing the  instrument  below  the  turbinate,  one  blade  of  the  V  being  in 
the  antrum  and  the  other  one  in  the  lower  meatus.  Gradually  depress 
the  handle  so  as  to  force  the  cutting  V  to  follow  as  close  to  the  floor 
of  the  nose  as  the  thickness  of  the  bone  at  this  part  will  permit,  causing 
it  finally  to  meet  the  incision  from  above  at  the  selected  spot.  The 
oval  piece  of  bone  made  up  of  turbinate  and  naso-antral  wall  is  re- 
moved with  forceps  en  masse.  (2)  For  an  opening  without  removal 
of  turbinal  tissue.     Enter  one  point  of  the  V  through  the  naso-antral 


Fjg.  321. — Stein's  antrum  chisel  or  gouge. 

wall  of  the  lower  meatus,  namely,  below  the  inferior  turbinate,  at  a 
point  as  high  up  mider  its  anterior  attachment  as  possible.  Push 
backward,  keeping  the  cutting  V  as  high  as  can  be.  When  the  desired 
length  of  incision  is  reached  remove  the  instrmnent  and  reintroduce 
at  the  beginning,  only  direct  the  cutting  V  as  close  to  the  floor  of  the 
meatus  as  possible,  driving  backward  to  meet  the  first  incision  above. 
By  using  two  instrimients,  ^^ith  one  blade  of  the  V  longer  than  the 
other,  this  latter  operation  is  made  easier,  the  longer  blade  being  the 
one  to  perforate  into  the  antrum." 

The  Kuster  Operation. — In  performing  this  operation  the  anterior 
wall  of  the  antrum  is  opened  through  the  canine  fossa.  This  opening 
should  be  large  enough  to  permit  the  introduction  of  the  index  finger. 
In  this  way  septa,  sequestra  of  dead  bone,  and  any  abnormality  in 
form  of  the  sinus  that  may  exist  can  be  recognized,  proper  treatment 
applied,  the  smus  curetted  and  packed. 

The  author's  method  of  performing  this  operation  is  illustrated  in 
Fig.  322. 

As  a  preliminary  step  the  naris  upon  the  affected  side  should  be 
packed  with  gauze  far  enough  back  to  cover  the  ostium  and  with  a 
portion  of  the  packing  projecting  out  from  the  nose  in  order  that  it 
33 


514 


DISEASES  OF  THE  MAXILLARY  SINUS 


may  be  quickly  removed  and  changed  if  necessary  and  that  there  may 
be  no  danger  of  its  working  back  into  the  pharynx  during  anesthesia. 
Unless  this  is  done  much  blood  may  be  lost  through  the  ostium  without 
its  quantity  being  noted,  and  hemorrhage  of  this  character  adds  con- 
siderably and  unnecessarily  to  the  danger  of  blood  inspiration.  Hav- 
ing packed  the  nose,  a  pad  consisting  of  two  or  three  gauze  sponges 
clamped  together  at  one  corner  with  the  forceps  is  placed  between 
the  teeth.  With  a  retractor  a  corner  of  the  mouth  is  drawn  back  out 
of  the  way.  If  necessary,  another  sponge  may  be  packed  into  the 
corner  of  the  mouth  with  a  forceps  attached  for  safety.  In  this  way 
the  patient  is  effectively  protected  against  the  danger  of  unusual 
hemorrhage,  and  the  field  of  operation  is  quite  clear. 


Fjg.  322. — Anterior  wall  of  the  maxillary  sinus  opened  at  the  canine  fossa. 


The  upper  lip  is  elevated  and  an  incision  made  at  the  labiogingival 
junction,  carried  to  the  periosteum,  and  made  sufficiently  long  to  give 
free  scope  in  the  removal  of  the  bony  wall.  Some  little  annoyance 
may  be  saved  by  picking  up  with  a  hemostat  any  small  vessels  which 
may  threaten  hemorrhage.  The  periosteimi  is  raised  sufficiently  to 
expose  the  canine  fossa. 

By  finger  pressure  the  most  yielding  place  in  the  anterior  wall  is 
readily  discovered.  The  bone  at  such  points  is  usually  suflficiently 
thin  to  admit  the  passage  of  a  reasonably  stiff  probe  directly  into  the 
sinus  in  an  upward,  backward,  and  inward  direction.  A  bur  in  a 
surgical  engine  is  then  passed  through  the  bone  following  the  direction 


THE  KUSTER  OPERATION  515 

of  the  probe.  The  purpose  of  this  is  to  prevent  the  possibility  of  such 
errors  as  have  frequently  occurred  when  through  some  anomaly  of  de- 
velopment of  the  sinus  is  unusually  small  and  the  naris  upon  the  affected 
side  much  enlarged;  or  when  some  other  unusual  anatomical  condition 
has  made  the  exact  situation  of  the  sinus  misleading,  as  a  result  of 
which  the  sinus  has  not  been  properly  entered.  The  author  has  known 
of  a  number  of  cases  in  which  irrigation  had  been  continued  for  a  long 
period  without  relief,  until  it  was  finally  discovered  that  the  opening 
made  led  into  the  nose  and  not  into  the  sinus. 

The  bur  is  then  carried  forward  vuitil  the  anterior  extremity  of  the 
sinus  is  reached,  and  backward  as  nearly  as  possible  to  its  full  extent 
in  a  posterior  direction.  The  floor  is  sloped  downward  as  much  as 
may  be  permitted  without  injury  to  the  apical  ends  of  the  roots  of 
the  teeth,  and  the  opening  enlarged  until  a  finger  can  be  inserted. 
When  hemorrhage  becomes  excessive,  packing  tightly  with  gauze  for  a 
few  minutes  will  usuall}^  serve  to  check  it  sufficiently  to  permit  careful 
progress  after  its,  removal. 

When  the  interior  of  the  sinus  is  thus  exposed  by  the  aid  of  properly 
adjusted  or  reflected  artificial  light,  satisfactory  examination  of  the 
actual  conditions  may  be  made.  One's  finger  quickly  becomes  accus- 
tomed to  areas  of  bone  that  are  rough  and  feel  dead  to  the  sense  of  the 
touch.  Bony  septa  may  be  mere  ridges  extending  across  the  floor 
of  the  sinus;  or  a  septum  may  extend  up  so  high  as  to  appear  to  form 
the  actual  sinus  wall,  and  thus  lead  the  operator  to  believe  that  the 
sinus  had  been  opened  completely,  when,  as  a  matter  of  fact,  the  most 
diseased  portion  may  lie  behind  this  barrier. 

Quite  recently  the  author  found  what  appeared  to  be  a  septum 
extending  almost  through  the  central  portion  of  an  unusually  large 
sinus,  and  later  discovered  that  it  was  the  nasal  wall  which  had  been 
forced  over  into  this  position. 

A  dental  or  surgical  engine  bur  should  not  be  trusted  as  a  substi- 
tute for  a  curette,  because  even  with  the  greatest  care  much  damage 
may  be  done  to  the  surrounding  parts.  A  bone  curette  will  readily 
remove  all  bone  that  should  come  away  except  such  as  hereafter 
described.  The  extent  of  curettement  depends  entirely  upon  the 
nature  of  the  disease.  In  long-standing  cases  of  chronic  empyema, 
when  there  has  been  extensive  destruction  of  the  lining  membrane, 
and  large  areas  of  diseased  bone  are  in  evidence,  the  curettage  must  be 
complete ;  but  when  polypi  are  found  and  the  lining  membrane  is  merely 
in  a  hyperplastic  condition,  it  is  better  not  to  make  such  extensive 
curettement  as  to  expose  the  bone  surface  entirely. 

Removal  of  the  polypi  and  diseased  mucous  surface  is  all  that  is 
required,  and  the  undisturbed  periosteum  favors  more  prompt  recovery 
than  when  the  bone  is  denuded. 

The  author's  experience  has  taught  him  that  when  antra  are  unusu- 
ally large,  with  an  extension  curving  backward  and  inward,  and  the 
extreme  point  of  the  inner  portion  of  this  wall  feels  rough  and  yielding. 


516 


DISEASES  OF  THE  MAXILLARY  SINUS 


it  is  advisable  to  puncture  in  order  to  ascertain  whether  or  not  there  is 
close  contact  with  a  diseased  sphenoidal  sinus  (Fig.  32.3). 

In  a  number  of  instances  when  patients  gave  a  history  of  at  least 
several  previous  radical  operations  for  empyema  of  the  maxillary  sinus, 
and  when  upon  opening  into  the  sinus  little  or  no  pus  was  found, 
puncture  at  this  point  allowed  pus  to  flow  in  considerable  quantities 
from  the  sphenoidal  sinus,  or  some  cell  connected  therewith,  which 
made  direct  communication  with  the  maxillary  sinus  possible.  After 
careful  curettement,  drainage,  and  irrigation,  these  cases  were  cured, 
as  they  otherwise  could  not  have  been,  even  though  the  sphenoidal 
sinus  might  have  been  opened  by  enlargement  of  its  ostium  and  treat- 
ment in  the  usual  manner. 

These  cases,  of  course,  are  rare,  but  they  are  likely  to  be  those  con- 
cerning which  the  prognosis  is  most  grave;  and  it  is  incumbent  upon 
the  operator  to  bear  in  mind  the  possibility  of  their  existence. 


A  B 

Fig.  323.— Anteroposterior  division  through  the  center  of  the  orbit,  maxillary  sinus, 
and  molar  teeth,  showing  a  large  maxillary  sinus  and  a  large  sphenoidal  sinus. 


In  chronic  cases,  when  the  sinus  has  been  sufficiently  curetted,  the 
pressure  against  the  nasal  wall  with  the  finger  inserted  through  the 
opening  in  the  anterior  wall  usually  reveals  that  the  bony  separation 
between  the  nose  and  the  maxillary  sinus  is  thin  and  more  or  less 
diseased.  This  thin  nasal  wall  can  usually  be  broken  quite  readily 
by  finger  pressure  and  the  thin  bony  flakes  drawn  away  through  the 
opening  in  the  sinus,  leaving  only  a  membranous  division  between 
these  two  cavities. 

This  not  only  removes  an  element  of  danger  of  recurrence  of  disease 
from  bone  affected  by  nasal  or  sinus  conditions,  but  it  leaves  the  case 
in  condition  to  be  readily  controlled  if  at  any  time  it  should  prove 
to  be  absolutely  necessary  to  have  a  large  opening  from  the  sinus  into 
the  nose,  because  it  is  only  necessary  in  that  event  to  cut  through  the 
soft  membrane. 

Last  of  all,  the  floor  of  the  orbit  should  be  carefully  examined. 


THE  KVSTER  OPERATION  5l7 

This  wall  is  undoubtedly  more  often  imperfect  than  the  average  opera- 
tor realizes.  The  bone  in  places  is  exceedingly  thin  and  non-resistant; 
many  times  its  surface  is  incomplete  as  a  result  of  destruction  by 
disease  or  anomalous  development,  and  there  will  be  found  to  be  one 
or  more  points  at  which  there  is  only  a  membranous  division  between 
the  orbit  and  the  sinus. 

Carelessness  in  curettement  under  these  circumstances  might  easily 
cause  serious  damage  to  the  organs  through  traumatic  injury  or 
infection. 

Care  should  be  taken  to  have  the  borders  of  the  opening  through 
the  canine  fossa  smooth  and  symmetrical  in  order  that  packing  may 
be  easily  performed  with  as  little  pain  as  possible.  It  should  be  packed 
wdth  gauze,  wrung  out  in  compound  tincture  of  benzoin,  or  2.5  per  cent, 
carbolic  acid,  or  m  syphilitic  cases  1  to  10,000  solution  of  bichloride  of 
mercury.  No  attempt  should  be  made  to  use  a  solution  that  might 
be  expected  to  act  as  a  powerful  germicide.  The  danger  of  irritation 
and  of  poisoning  is  too  great.  The  purpose  should  be  to  prevent  the 
gauze  itself  becoming  a  source  of  infection  through  absorption  of  bac- 
teria-laden secretions.  There  is  no  need  of  powerful  germicides  when 
the  work  has  been  thoroughly  performed  with  proper  surgical  cleanli- 
ness. Gauze  used  for  packing  should  be  folded  into  a  long,  narrow 
strip  with  the  edges  so  turned  in  that  threads  of  the  gauze  may  not 
become  detached  and  cling  to  the  walls  of  a  sinus  at  the  time  of  removal, 
and  thus  become  a  source  of  future  infection.  The  strip  should  be 
sufficiently  long  to  fill  the  sinus  completely  and  thus  avoid  error  at 
the  time  of  removal,  because  there  will  then  be  no  chance  of  any  por- 
tion bemg  left  behind.  ^Moreover,  its  removal  is  facilitated,  because 
it  can  be  drawn  out  continuously  from  one  end;  and  when  packed 
into  place  a  suflBcient  pressure  will  be  made  to  check  tendency  to 
hemorrhage  and  to  force  the  tissues  away  from  the  opening  and  give 
as  unobstructed  a  view  of  the  mterior  of  the  sinus  as  possible  when  the 
packing  is  removed.  The  buccal  surface  should  be  coated  freely  with 
collodion  to  keep  out  secretions  and  hold  the  gauze  perfectly  in  place. 

The  first  packing  under  ordinary  conditions  may  be  safely  left 
forty-eight  hours.  This  gives  the  patient  tune  to  recover  from  the 
effects  of  the  operation.  Afterward  it  should  be  changed  daily,  using 
a  little  less  pressure  from  day  to  day.  The  number  of  times  that  the 
sinus  should  be  packed  will  depend  upon  the  character  of  the  disease. 
On  general  principles  the  less  packing  an  antrum  receives  beyond 
actual  requirements  the  more  will  its  return  to  healthy  conditions  be 
encouraged.  In  ordinary  cases  from  one  to  three  packings  is  sufficient. 
Old  chronic  cases  may  require  the  dressing  to  be  changed  daily  for 
ten  days. 

The  purpose  of  the  packing  is  to  allow  the  wound  to  become  pro- 
tected to  some  extent  against  infection  by  the  formation  of  new  granu- 
lations. As  soon  as  this  is  accomplished  the  packing  is  left  out  and  the 
patient  instructed  to  irrigate  through  the  sinus  with  saline  or  boric 


518 


DISEASES  OF  THE  MAXILLARY  SINUS 


solution  twice  daily.  At  intervals  of  two  or  three  clays  a  swab  dipped 
in  tincture  of  iodin  may  be  used  to  wipe  out  the  inner  surface  and  the 
borders  of  the  buccal  opening. 

The  capillary  drainage  supplied  by  the  gauze  packing  is  undoubtedly 
an  important  factor,  and  much  more  effective  than  drainage  tubes  of 
any  kind  could  be. 

Most  operators  who  have  had  occasion  to  treat  chronic  cases  of 
empyema  of  the  maxillary  sinus,  which  had  previously  been  treated 
according  to  the  methods  of  a  decade  ago,  will  remember  how  often  it 
occurred  that  foreign  bodies  found  their  way  into  the  antrum  through 
small  openings,  especially  when  treatment  was  made  through  the 
socket  of  the  root  of  a  tooth.  When  these  sinuses  were  properly 
opened  up  all  kinds  of  foreign  substances  were  from  time  to  time 
found  lodged  therein,  such  as  old,  foul-smelling  pieces  of  cotton,  pieces 
of  gauze,  hard-  and  soft-rubber  tubes,  metal  tubes,  portions  of  roots  of 
teeth,  pieces  of  instruments,  fragments  of  wooden  toothpicks,  insoluble 
particles  of  food,  etc. 


Fig.  324.— Woman  with  chronic  disease  of  both  frontal  and  maxillary  disuses.    External 
fistulge  are  shown  at  nose,  eye,  and  brow. 


Fig.  324  shows  the  picture  of  a  patient,  a  woman,  aged  forty-eight 
years,  who  had  been  operated  on  through  a  small  opening  in  the 
canine  fossa,  and  had  a  Kilian  operation  performed  upon  her  frontal 
At  the  time  she  came  under  the  author's  care,  pus  was  dis- 


smus. 


charging  so  freely  from  the  frontal  sinus,  and  through  the  side  of 
the  nose  and  maxillary  sinus,  that  there  was  almost  a  continuous  flow 
which  dripped  out  upon  the  face.  Upon  examination  it  was  found 
that  her  nose  contained  approximately  two  inches  of  badly  rotted 
rubber  tubing  that  had  been  passed  from  the  mouth  into  the  sinus  and 


THE  CALDW ELL-LUC  OPERATION  519 

had  worked  out  through  the  ostium  into  the  nose.  This  tubing  had 
been  lodged  in  that  position  for  about  two  years.  This  was  removed, 
and  when  the  maxillary  sinus  was  properly  opened  it  was  found  to  be 
partially  filled  with  black-looking  particles,  which  proved  to  be  bismuth 
paste,  that  had  been  forced  into  the  sinus  evidently  in  the  fond  hope 
that  it  might  effect  a  cure,  notwithstanding  the  surrounding  conditions. 
One  complete  operation,  which  included  the  maxillary  sinus,  the  side 
of  the  nose,  and  the  frontal  sinus,  was  all  that  was  necessary  to  check 
the  offensive  pus  formation  and  set  in  motion  progress  toward  com- 
plete recovers^  which  followed  shortly  afterward. 

This  is  simply  a  marked  illustration,  but  in  its  main  aspect  it  is 
not  unusual.  The  author  has  never  had  much  sympathy  with  the  use 
of  bismuth  paste  (Beck's  paste)  in  the  treatment  of  maxillary  sinus 
disease.  For  it  has  always  seemed  that  there  was  no  advantage  in 
attempting  to  avoid  the  thorough  and  complete  radical  operation 
which  such  cases  require;  and  that  even  though  the  bismuth  paste 
might  be  effective  in  some  cases,  its  use  is  unnecessary. 

Removal  of  Foreign  Bodies  from  the  Maxillary  Sinus. — ^^^len  the 
roots  of  teeth  from  extraction  have  been  forced  into  the  maxillary 
sinus,  or  any  other  foreign  substances  that  cannot  be  expected  to 
pass  safely  out  through  the  ostium,  even  though  apparently  harmless, 
they  should  be  removed  by  opening  up  the  sinus,  as  for  the  performance 
of  a  radical  operation. 

The  author,  after  a  number  of  years  of  rather  wide  experience  in 
the  treatment  of  maxillary  sinus  disease,  has  opened  the  sinus  many 
times  without  an  anesthetic;  has  used  local  anesthesia,  nitrous  oxide, 
oxygen,  and  ether,  but  has  found  ether  the  most  reliable  when  radical 
operation  is  performed. 

Caldwell-Luc  Operation. — In  this  operation  (see  Fig.  325)  the  anterior 
wall  of  the  antrum  is  exposed  by  an  incision  at  the  labiogingival 
junction,  and  the  bone  surface  uncovered  by  separation  of  the  peri- 
osteum and  overlying  tissues,  in  the  same  manner  as  for  the  Kuster 
operation,  except  that  it  is  more  carefully  done  in  order  to  favor 
closure  of  the  wound  by  sutures. 

The  bony  wall  is  removed  in  precisely  the  same  way.  A  large  open- 
ing is  then  made  through  the  naso-antral  wall.  To  accomplish  this 
the  anterior  half  of  the  inferior  turbinated  body  is  sometimes  removed 
'^'ith  a  swivel  knife  or  -^ith  scissors  or  with  a  saw,  and  the  opening  from 
the  nose  into  the  sinus  effected  by  the  use  of  specially  formed  chisels 
and  saws,  or  with  a  Nobel-Cordes  forceps  (as  shown  in  Fig.  320), 
or  some  similar  instrument;  or  the  naso-antral  opening  may  be  made 
from  the  antral  side,  entrance  being  gained  through  the  oro-antral 
opening,  as  prescribed  for  the  Kuster  operation,  except  that  it  is  carried 
completely  through  the  mucous  membrane  and  a  large  naso-antral 
opening  established.  The  end  of  a  strip  of  gauze  packing  of  sufficient 
length  is  carried  into  the  sinus  through  the  oral  opening  and  out  through 
the  nasal  opening  into  the  nose,  and  its  left  sHghtly  projecting  from  the 


Fig.    325. — Anterior  wall  of  the  maxillary  &imis  opened  for  the  Caldwell-Luc  operation 

1 


Fio.  .326. — r;ikhvell-Luc  operation  completed  by  r-losure  of  the  oro-aiilral  openina. 


THE  DENKER  OPERATION  521 

external  opening.  With  the  remaining  portion  of  the  gauze  strip  the 
sinus  is  packed  in  such  a  manner  as  to  permit  of  the  immediate  closure 
of  the  oral  wound  with  catgut  sutures,  as  illustrated  in  Fig.  326. 

At  the  end  of  the  second  day  the  gauze  packing  is  finally  withdrawn 
through  the  nose,  future  treatment  being  in  the  nature  of  irrigation 
with  mild  antiseptic  solutions. 

The  Danker  Operation  (Fig.  327) . — In  the  Denker  operation  the  ante- 
rior wall  of  the  maxillary  sinus  is  removed  in  the  same  manner  as  in 
the  Kuster  and  Cald well-Luc  operations;  and  in  addition  to  this  the 
remaining  section  of  the  bone  between  the  canine  fossa  and  the  lower 
portion  of  the  pyriform  opening  ol  the  nose  is  cut  away.     The  sinus 


Fig.  327. — The  Dcaker  antrum  operation:  a,  the  area  of  bone  removed  in  the  Kuster 
and  the  Caldwell-Luc  operations.  In  the  Denker  operation  additional  bone  is  removed 
from  b  to  the  pyriform  aperture.     (Ballenger.) 

is  curetted  and  diseased  membrane,  granulation  tissue,  polypi,  or  dead 
bone  removed.  The  mucoperiosteum  of  the  anterior  meatus  of  the 
nose  and  of  the  inferior  turbinated  body  is  detached  with  a  small,  flat 
periosteal  elevator  of  such  form  as  to  make  it  adaptable  to  the  parts. 
From  this  a  mucoperiosteal  rectangular  flap  is  cut  and  turned  outward 
onto  the  floor  of  the  sinus.  The  bony  naso-antral  wall  and  the  anterior 
portion  of  the  inferior  turbinated  body  are  cut  away  sufficiently  to 
make  as  large  an  opening  as  for  the  Caldwell-Luc  operation.  The 
mucoperiosteal  flap  which  has  been  turned  onto  the  floor  of  the  sinus 
is  held  into  position  for  from  twenty-four  to  forty-eight  hours  with  a 
bismuth  gauze  dressing. 
In  after-treatment  the  parts  are  kept  cleansed  and  the  tissue,  as 


522 


DISEASES  OF  THE  MAXILLARY  SINUS 


granulation  takes  place,  is  touched  from  time  to  time  with  tincture  of 
iodin  or  caustics  if  required  to  check  excessive  granulation. 


Fig.  32S.  —  Canfield-Ballenger  opera- 
tion: a,  the  margin  of  the  pyriform  aper- 
ture, the  point  of  incision  for  the  Canfield- 
Ballenger  antrum  operation.     (Ballenger.) 


Fig.  329. — Canfield-Ballenger     opera- 
tion: b,  the  incision.     (Ballenger.) 


Fig.  330.  —  Canfield-Ballenger  opera- 
tion: c,  the  naso-antral  angle  removed, 
thereby  exposing  the  cavity  of  the  antrum. 
(Ballenger.) 


Fig.  331. — -Canfield-Ballenger  opera- 
tion :  d,  the  naso-antral  wall  being  severed 
with  the  Wagener  forceps.     (Ballenger.) 


Canfield-Ballenger  Antrum  Operation. — This  operation  is  illustrated 
by  Figs.  328,  329,  330,  331  and  332,  and  is  described  by  Ballenger 
as  follows: 


CANFIELD-BALLENGER  ANTRUM  OPERATION 


523 


"  Technic. — Anesthesia:  (a)  Induce  anesthesia  of  the  nasal  mucous 
membrane  by  the  local  application  of  cocain  or  any  other  drug  pre- 
ferred ;  (6)  induce  anesthesia  of  the  vestibular  skin  of  the  naris  by  the 
injection  of  Schleich's  solution.  This  solution  should  also  be  injected 
beneath  the  periosteum  of  the  canine  fossa  via  the  vestibule  of  the  nose. 

"Incision. — Distend  the  wing  of  the  nose  with  a  nasal  speculum, 
as  shown  in  Fig.  328,  to  bring  the  anterior  angle  of  the  naso-antral 
wall  into  prominence.  Then  with  a  small  scalpel  make  an  incision 
the  whole  length  of  the  exposed  portion  of  the  naso-antral  angle 
(margin  of  the  pyriform  aperture,  Fig.  329).  Then  elevate  the  mem- 
brane, including  the  periosteum  over  the  canine  fossa  (Fig.  330) . 


Fig.  332. — Interior  view  of  the  Canfield-Ballenger  antrum  operation:  a,  middle 
turbinal;  b,  line  of  attachment  of  the  inferior  turbinal,  which  is  left  intact;  c,  the  naso- 
antral  wall  removed,  extending  from  the  floor  of  the  nose  to  the  attachment  of  the  inferior 
turbinal  and  from  the  anterior  to  the  posterior  Umits  of  the  antrum. 


"  Oyeiiing  the  Naso-antral  Angle. — ^The  antrum  should  be  opened  via 
the  naso-antral  angle  (margopyriformis)  with  rongeur  bone  forceps, 
as  shown  in  Fig.  330,  or  with  a  gouge  and  mallet.  In  some  subjects 
the  bone  at  this  angle  is  dense,  requiring  considerable  force  to  bite 
through  it,  while  in  others  it  is  extremely  thin  and  easily  removed. 
While  the  incision  extends  higher  than  the  attachment  of  the  inferior 
turbinal  (to  allow  retraction),  the  bone  at  the  angles  should  only  be 
removed  below  the  line  of  attachment  of  the  inferior  turbinated 
body.  In  removing  the  bone  constituting  the  canine  fossa,  it  is 
usually  only  necessary  to  remove  enough  to  admit  of  the  introduction 


524  DISEASES  OF  THE  MAXILLARY  SINUS 

of  the  Wagener  antrum  forceps,  as  shown  in  Fig.  331.  If,  however, 
after  making  the  opening  through  the  naso-antral  angle  it  is  determined 
that  the  whole  of  the  mucous  membrane  is  not  accessible  to  the  curette, 
as  much  of  the  canine  wall  may  be  removed  as  will  fully  expose  it. 

"  Removal  of  the  Naso-antral  Wall. — ^The  biting  jaws  of  the  Wagener 
forceps  (Fig.  331)  are  placed  astride  the  naso-antral  wall  and  the  wall 
bitten  away  from  the  attachment  of  the  inferior  turbinate  body 
down  to  the  floor  (Fig.  332).  This  makes  an  opening  about  one  and 
one-half  by  five-eighths  inches  in  size.  An  opening  of  this  size  will 
never  close  by  granulation.  It  was  formerly  thought  necessary  to 
also  remove  the  anterior  half  of  the  inferior  turbinate  body,  to  expose 
the  naso-antral  wall  to  surgical  interference.  By  this  method  it  is 
rendered  unnecessary,  hence  the  inferior  turbinal  is  unmolested  and 
is  preserved  and  continues  to  perform  its  respiratory  functions. 

"Intermediate  and  After-treatment.- — If  the  mucous  membrane  of 
the  antrum  is  edematous  and  has  not  undergone  polypoid  or  granu- 
lation degeneration,  it  is  not  necessary  to  curette  it  away  (Myles). 
When  such  a  pathological  condition  is  present,  packing  the  antrum 
with  gauze  moistened  with  the  compound  tincture  of  benzoin  daily 
for  three  or  four  days  will  relieve  the  edema,  and  the  mucous  membrane 
will  resume  its  normal  structure  and  function.  When,  however,  the 
mucous  membrane  is  converted  into  large  granulation  masses  or  polypi, 
it  should  be  thoroughly  removed  with  a  sharp  curette,  thereby  denuding 
the  bony  walls.  If  this  is  done  a  new  mucous  membrane  will  not  form, 
but  the  walls  will  become  covered  with  thick  fibrous  tissue,  which 
partially  obliterates  the  antral  cavity.  Such  tissue  does  not  develop 
columnar  epithelium,  but  continues  to  secrete  a  semipurulent  fluid. 
For  this  reason,  curettage  should  be  avoided  unless  the  pathological 
condition  warrants  it. 

"After  three  or  four  days  the  gauze  dressings  should  be  discontinued. 
The  cavity  may  then  be  swabbed  or  sprayed  daily  with  a  10  per  cent, 
solution  of  ichthyol  to  stimulate  local  hyperemia  and  leukocytosis 
(raise  the  resistance;  raise  the  opsonic  index),  thereby  hastening  the 
reparative  process. 

'*In  conclusion,  I  wish  to  say  that  this  method  of  operating  is  (a) 
radical,  inasmuch  as  it  fully  exposes  the  cavity  of  the  antrum  to 
inspection  and  treatment;  (6)  it  is  conservative,  as  it  is  attended  by  the 
least  possible  destruction  of  the  physiological  structures,  particularly 
the  inferior  turbinal,  which  is  neither  temporarily  nor  permanently 
resected;  (c)  furthermore,  the  operation  may  be  done  under  local 
anesthesia,  whereas  other  operations  equally  radical  (and  more  destruc- 
tive) must  be  done  under  general  anesthesia;  {d)  the  time  required  for 
this  operation  is  much  less  than  that  for  other  radical  operations."^ 

Comparative  Review  of  the  Several  Maxillary  Sinus  Operations.^ 
It  should  be  remembered  that  many  acute  diseases  of  the  maxillary 

*  Ballenger:  Diseases  of  the  Nose,  Throat,  and  Ear,  1914,  4th  ed. 


REVIEW  OF  THE  MAXILLARY  SINUS  OPERATIONS         525 

sinus  recover  without  treatment.  As  the  inflammatory  symptoms 
subside  and  the  ostium  becomes  patent,  natural  drainage  takes  place 
and  the  excessive  and  frequently  offensive  secretion  disappears,  with 
ultimate  complete  resumption  of  normal  function. 

Proper  treatment  of  intranasal  conditions  is  required  to  relieve  the 
,  acute  rhinitis  which  is  a  natural  associate  of  acute  sinuitis. 

In  this  connection  it  must  be  urged  that  the  prime  requisite  in  the 
treatment  of  all  diseases  of  the  maxillary,  as  of  the  other  nasal  acces- 
sory sinuses,  is  the  removal  of  the  first  cause  of  the  disease.  Any  nasal 
obstruction  or  intranasal  defect  which  may  act  as  a  predisposing  factor 
should  receive  appropriate  treatment. 

Operative  treatment  of  the  sinus  itself  therefore  should  be  resorted 
to  only  when  absolutely  required. 

Puncture  and  irrigation  through  the  naso-antral  wall  is  all  that  is 
required  in  many  acute  cases.  When  the  nature  of  the  case  demands 
other  treatment,  this,  of  course,  should  be  given,  but  radical  means 
should  not  be  employed  unless  it  has  been  demonstrated  that  this  treat- 
ment is  insufficient,  or  when  there  are  indications  present  which  make 
it  apparent  at  the  outset  that  more  extensive  opening  is  necessary. 

The  alveolar  and  palatal  points  of  entrance  are  objectionable  for  the 
reasons  stated  in  the  description  of  these  operations. 

The  intranasal  operation  is  usually  all-sufficient,  and  in  these  cases 
is  by  all  means  the  operation  of  choice.  . 

The  reasons  why  it  is  not  adequate  to  the  requirements  of  certain 
cases  are  that  it  is  not  practicable  to  curette  the  antrum  satisfactorily 
when  it  is  unusual  in  size  or  form  and  contains  granulation  tissue, 
pol}T)i,  or  diseased  bone,  requiring  complete  and  thorough  removal. 

While  in  most  cases  a  large  opening  in  the  naso-antral  wall  gives 
sufficiently  complete  drainage,  it  is  well  known  that  the  floor  of  the 
antrum  is  frequently  lower  than  instead  of  on  a  level  with  or  higher 
than  the  floor  of  the  nose. 

Thus  the  question  of  perfect  drainage  is  somewhat  problematical 
from  this  aspect. 

The  CakhveU-Lvc  operation  is  quite  generally  advocated  and  does  give 
opportunity  for  access  to  all  parts  of  the  sinus.  It  has  the  added  advan- 
tage which  is  gained  by  a  large  opening  through  the  naso-antral  wall, 
and  immediate  closm-e  of  the  opening  in  the  oro-antral  wall  by  sutures. 
While  it  may  not  give  as  complete  freedom  from  infection  by  mouth 
bacteria  as  is  claimed,  it  certainly  reduces  the  danger  in  this  direction 
to  a  minimum.  In  such  cases  as  are  adaptable  to  this  operation  the 
results  would  unquestionably  be  more  satisfactory  than  with  the 
Kuster  operation. 

The  author's  experience  lends  support  to  the  opinion  that  there 
are  occasional  conditions  in  which  it  is  most  desirable  that  the  oro- 
antral  opening  be  maintained  for  a  longer  period  than  that  required 
by  the  technic  of  the  Cald well-Luc  operation.  The  intranasal  opera- 
tion is  unsatisfactory  when  conditions  are  such  as  to  require  unob- 


526  DISEASES  OF  THE  MAXILLARY  SINUS 

structed  access  to  all  parts  of  the  sinus,  however  irregular  its  shape 
may  be,  and  more  or  less  long-continued  capillary  drainage  by  means 
of  gauze  packing.  The  author  believes  that  in  certain  cases  these 
are  important  advantages  in  the  Kuster  operation  in  comparison  with 
the  results  of  the  immediate  closure  of  the  oro-antral  wall  as  performed 
in  the  Caldwell-Luc  operation. 

For  example,  one  of  the  author's  patients  had  a  history  of  antral 
disease  extending  over  a  period  of  approximately  fifteen  years,  dur- 
ing which  time  many  operations  of  various  kinds  had  been  performed 
with  unsatisfactory  results.  When  operated  upon,  and  when  the 
sinus  was  completely  opened,  a  large  black  sequestrum  of  bone,  which 
included  almost  the  entire  floor  of  the  sinus,  was  found.  It  had 
evidently  been  there  during  all  of  the  fifteen  years  since  an  attack 
of  typhoid  fever,  and  by  its  situation  was  prevented  from  exfoliating. 
The  sequestrum,  evidently  a  result  of  exanthematous  necrosis,  had 
remained  as  a  sequel  of  this  disease.  x\s  a  matter  of  course  it  was 
impossible  to  relieve  this  condition  by  any  sort  of  intranasal  opera- 
tion. It  would  have  been  equally  inadvisable  to  close  the  oro-antral 
opening  in  such  a  case  until  after  the  local  results  of  the  necrosis  had 
been  overcome. 

As  has  already  been  stated,  it  has  not  infrequently  happened,  in 
the  treatment  of  the  author's  patients,  that  a  connection  has  been 
found  between  the  maxillary  sinus  and  some  extension  or  cell  from 
the  sphenoidal  sinus.  Under  these  conditions  it  seems  as  though 
there  could  be  no  question  as  to  the  value  of  keeping  a  maxillary  sinus 
packed  with  gauze  and  freely  open  for  a  sufficient  time  to  effect  a 
cure  of  the  sphenoidal  sinus  disease  as  well  as  that  of  the  maxillary 
sinus. 

There  are  some  cases  also  in  which  it  seems  to  be  expedient  to 
continue  drainage  for  the  benefit  of  the  ethmoidal  cells  and  the  frontal 
sinus,  when  through  unusual  conditions  there  is  a  more  than  ordi- 
narily direct  communication  for  the  transmission  and  continuance  of 
infection. 

The  DenJier  operation  appears  to  be  quite  unnecessary,  more  espe- 
cially because  the  Canfield-Ballenger  operation  seems  to  give  all 
the  advantages  of  the  Denker  operation  in  the  way  of  opening  the 
antrimi  and  securing  free  access,  without  the  same  degree  of  disad- 
vantageous opportunity  for  mouth  infection. 

Whether  the  loss  of  bone  attachment  occasioned  by  removal  of  the 
intervening  portion  of  the  bone  between  the  opening  of  the  canine 
fossa  and  the  naris,  as  described  in  both  the  Denker  and  Canfield- 
Ballenger  operations,  could  by  any  possibility  interfere  with  the 
function  or  appearance  of  the  lip  or  face  muscles,  through  destruction 
of  their  point  of  attachment,  the  author  is  not  prepared  to  say.  While 
he  is  convinced  that  unusual  cases  of  necrosis  or  pus  formation  in 
closely  adjacent  extensions  from  the  sphenoidal  sinus  could  be  reached 
only  with  much  difficulty,  if  at  all,  through  an  opening  such  as  that 


OPERATIONS  UPON   THE  MAXILLARY  SINUS  527 

described  for  the  Canfield-Ballenger  operation,  yet  he  feels  assured 
that  if  these  objections  are  or  can  be  overcome,  such  an  operation 
would  undoubtedly  be  an  improvement  over  all  the  others 

Operations  upon  the  Maxillary  Sinus  from,  the  Point  of  View  of  the 
Oral  Surgeon. — Strictly  speaking,  it  may  be  said  that  the  treatment 
of  the  maxihary  sinuses,  in  common  with  the  other  nasal  accessory 
sinuses,  belongs  largely  to  the  field  of  rhinology,  except  when  etiologi- 
cal factors  or  pathological  conditions  related  to  oral  diseases  exist. . 

^Yith  the  acute  and  other  less  grave  maxillary  sinus  affections 
eliminated,  the  work  of  the  oral  surgeon  naturally  resolves  itself  into 
the  treatment  of  pathological  conditions  of  the  maxillary  antra, 
which  have  not  yielded,  or  may  not  be  expected  to  yield,  to  intra- 
nasal or  other  methods  of  treatment,  except  such  as  give  opportunity 
for  complete  radical  removal  of  diseased  tissues  from  every  part  of  the 
maxillary  sinus. 

In  the  author's  experience  the  danger  of  infection  of  maxillary 
antra  through  an  oro-antral  opening,  by  mouth  bacteria,  is  not  serious 
if  packing  has  been  properly  inserted  and  renewed  with  sufficient 
frequency  to  protect  the  sinus  until  such  time  as  nature  has  had 
opportunity  to  guard  the  recently  curetted  surfaces  by  granulation, 
and  if  the  antrum  is  frequently  irrigated  with  normal  salt  solution  or 
any  mildly  antiseptic  non-irritating  preparation.  The  opportunity 
for  continuous  irrigation  and  drainage  in  some  instances  is  essentially 
valuable.  In  short,  cases  can  be  cured  in  this  way  that  seem  to 
resist  every  other  method  of  treatment.  In  making  this  statement 
the  author  is  fully  aware  that  in  many  other  cases  both  the  intranasal 
and  the  Caldwell-Luc  operations  may  give  apparently  quite  as  satis- 
factory results,  with  less  postoperative  treatment. 

It  naturally  happens  that  the  classes  of  cases  which  come  to  the 
oral  sm-geon  for  treatment  are  such  as  have  resisted  other  methods, 
and  the  great  majority  of  these  require  more  than  ordinarily  thorough 
treatment,  which  precludes  the  expectations  of  prompt  recovery. 

Fig.  324,  illustrating  a  case  already  described,  is  another  example 
of  the  complications  that  make  it  advisable  not  only  to  have  free 
access  to  all  parts  of  the  maxillary  sinus  but  to  have  an  equally  good 
opportunity  for  observation  of  its  inner  surface  and  the  surrounding 
parts  diuing  postoperative  treatment. 

In  another  case,  in  a  man  who  had  had  many  operations  in  this 
country  and  in  Emope  dming  a  period  of  more  than  five  years,  a 
considerable  quantity  of  diseased  bone  was  found  in  the  region  of  the 
floor  of  the  sinus.  It  would  undoubtedly  have  escaped  notice  at 
the  time  of  the  author's  operation,  as  it  did  at  the  time  of  previous 
operations,  if  the  wide  opening  in  the  oro-antral  wall,  and  the  situa- 
tion disclosed  in  the  course  of  repeated  packing,  had  not  aft'orded 
opportunity  for  the  observation  and  study  of  actual  bone  conditions. 
In  this  way  the  real  cause  of  the  continuance  of  the  disease  was  readily 
discovered,  and  therefore  cure  brought  about. 


528  DISEASES  OF  THE  MAXILLARY  SINUS 

A  great  number  of  cases  in  the  author's  practice  could,  if  necessary, 
be  cited  to  emphasize  the  almost  incalculable  value  of  this  treatment. 
At  the  same  time  he  is  fully  alive  to  the  advantages  of  other  methods 
in  suitable  cases. 

Foreign  Bodies  in  the  Maxillary  Sinus. — ^It  is  not  unusual  for  foreign 
bodies  to  find  their  way  into  the  maxillary  antrum.  Teeth  or  por- 
tions of  their  roots  or  cro^^iis,  or  pieces  of  bone,  have  often  been  forced 
into  the  sinus  in  attempted  tooth  extraction.  Drainage  tubes,  such 
as  the  piece  of  rubber  tubing  that  has  already  been  described  with 
reference  to  one  of  the  author's  cases,  tubes  of  ^'ulcanite  and  of  differ- 
ent kinds  of  metal,  were  commonly  found  in  this  situation  when  the 
use  of  drainage  was  generally  employed  in  treatment  of  these  cases. 
Balls  of  cotton  or  strips  of  gauze  and  small  instruments  frequently 
escape  through  openings  in  the  antral  walls  when  through  misguided 
surgical  treatment  they  have  not  been  sufficiently  enlarged.  Pieces 
of  metal  and  other  foreign  substances  have  often  been  forced  through 
the  walls  by  gunshot  or  other  severe  traumatic  injuries.  Sometimes 
foreign  bodies  have  remained  in  this  situation,  and  attempts  to  cure 
such  cases  were  necessarily  ineffective,  until  the  real  cause  of  con- 
tinued irritation  was  discovered  and  removed. 

Symptoms  and  Diagnosis. — Foreign  substances  in  the  maxillary 
sinus ;  usually  cause  continued  inflammation  with  excessive  or  offen- 
sive purulent  discharge,  in  accordance  with  the  nature  of  the  sub- 
stance. In  diagnosis,  under  some  circumstances,  alteration  of  the 
form  of  the  walls  might  be  noticed;  as  a  rule,  however,  such  bodies 
are  best  diagnosticated  with  the  Roentgen  rays.  Under  favorable 
conditions  they  have  been  felt  and  located  by  probing  through  the 
external  opening,  but  this  cannot  be  depended  upon  in  all  cases. 

Treatment.- — The  first  step  toward  cure  must  necessarily  be  removal 
of  the  foreign  substance,  whatever  it  may  be.  Usually  this  involves 
a  radical  operation,  but  when  once  the  source  of  irritation  has  been 
relieved  the  treatment  of  such  a  sinus  is  identical  with  that  which  would 
be  indicated  for  any  similar  pathological  affection  or  lesion. 

Infectious  Diseases. — Symptonas. — All  of  the  exanthemata  and  other 
infectious  diseases,  such  as  tuberculosis,  syphilis,  actinomycosis,  etc., 
are  prone  to  attack  the  maxillary  sinus,  because  of  its  double  sus- 
ceptibility through  the  mucous  membrane  of  the  nose  and  periosteum 
of  the  bone. 

The  symptoms  under  these  circumstances  are  identical  with  any 
other  indication  of  the  disease,  whatever  it  may  be,  in  a  similar  situ- 
ation. 

Treatment.— The  treatment  of  infectious  diseases  affecting  the 
maxillary  sinus  resolves  itself  into  an  effort  to  overcome  the  depleting 
effect  of  the  disease  upon  the  system,  and  to  relieve  the  local  lesion. 
For  example,  s>-philis  may  attack  the  lining  membrane  of  the  sinus 
by  s\-philitic  ulceration  or  gummatous  formation,  or  it  may  bring 
about  s}-philitic  necrosis  with  extensive  bone  destruction.     Under  all 


TUMORS  OF  THE  MAXILLARY  SINUS  529 

of  these  circumstances  the  first  consideration  must  be  the  Consti- 
tutional treatment  of  the  disease  and  the  upbuilding  of  the  patient 
to  increase  resistance,  supplemented  by  local  measures  in  the  way  of 
direct  treatment  of  the  lesion  itself.  Precisely  the  same  principles 
must  govern  the  treatment  of  all  other  antral  affections  occurring 
secondarily  to  infectious  diseases. 

Pol3T)i. — Hyperplasia  of  the  mucous  membrane  in  the  form  of 
polypi  is  a  common  feature  of  sinuitis  with  or  without  pus,  and  would 
be  treated  altogether  as  a  s^Tnptom  rather  than  a  distinct  affection, 
as  the  term  is  commonly  used,  were  it  not  for  the  fact  that  poh'pi 
may  also  be  tumors  of  fibroid,  myxomatous  or  even  sarcomatous  types. 
Their  symptoms  and  treatment  are  included  in  the  descriptions  of  the 
sinus  diseases  and  tumors  with  which  they  are  associated. 

Polj'pi  have  been' held  by  some  writers  to  be  pathognomonic  of 
sinus  suppuration;  but  after  careful  consideration  of  the  many  vary- 
ing reports,  the  only  point  that  really  seems  clear  is  that  their  presence 
or  absence  is  not  a  matter  of  great  significance  except"  with  regard 
to  treatment. 

Cysts. — Cysts  of  the  maxillary  antrum  are  not  uncommon,  and 
may  be  formed  by  the  distention  of  the  mucous  glands  quite  similar 
to  mucous  cysts  in  other  situations.  These  may  be  small  or  so  large 
as  almost  or  entirely  to  fill  the  cavity  of  the  sinus.  Upon  puncture 
they  are  found  to  contain  mucous,  mucopus,  or  serum. 

Dentigeroiis  cysts  may  be  so  situated  as  to  be  partly  or  entirely 
within  the  maxillary  sinus. 

Dental  cysts  may  form  from  diseases  of  the  teeth  and  extend  into 
this  sinus,  and  in  the  course  of  their  enlargement  may  encroach  upon 
surrounding  parts  sufficiently  to  cause  more  or  less  disturbance  or 
even  deformity  through  alteration  of  the  form  of  the  bony  walls. 

Treatment. — A  mucous  cyst  requires  the  complete  opening  of  the 
sinus  and  removal  or  obliteration  of  the  cyst  wall. 

In  the  treatment  of  both  dentigerous  and  dental  cysts  care  should 
be  taken  to  prevent  infection  of  the  lining  membrane  of  the  antrum, 
which,  although  it  may  be  forced  into  exceedingly  small  compass,  is 
nevertheless  usually  found  to  be  intact,  and  under  proper  treatment 
of  the  cyst,  through  the  external  opening,  will  again  be  restored  to 
its  normal  situation  and  condition. 

Cystocele. — It  has  been  claimed  that  the  entire  sinus  may  become 
encysted  under  certain  conditions  through  the  collection  of  fluid 
when  the  ostium  is  completely  obstructed.  ]Many  such  cases  are 
reported,  but  the  evidence  appears  to  rest  upon  the  point  that  when 
opened  the  sinus  was  found  to  be  filled  with  serous  fluid  and  the  ostimn 
closed.  But  there  appears  to  be  an  element  of  doubt  in  all  these  cases 
as  to  whether  the  condition  was  really  one  of  cystocele  or  an  enlarged 
mucous  cyst. 

Tumors. — ^Tumors  of    the    maxillary    sinus    are    nor    uncommon. 
Failure  to  discover  the  disease  in  clironic  cases  seems  to  ofl^er  a  favor- 
34 


530  DISEASES  OF  THE  MAXILLARY  SINUS 

able  opportunity  in  this  situation  for  the  formation  of  malignant 
growths.  Many  of  the  author's  cases  of  sarcoma  and  carcinoma 
began  in  the  maxillary  sinus. 

The  etiology,  sjnnptoms,  and  treatment  of  neoplasms  affecting  this 
region  are  similar  to  those  described  under  Tumors. 

The  necessity  for  prompt  and  careful  diagnosis,  however,  cannot 
be  too  frequently  urged.  It  is  sometimes  confusing  to  differentiate 
between  the  gumma  of  syphilis,  distortion  of  the  anterior  wall  of 
the  sinus  from  a  cyst,  or  destruction  of  the  bony  walls  from  long- 
continued  suppuration  in  malignant  growths. 

It  may  be  said  in  general  terms  that  when  an  enlargement  in  this 
region  is  opened  with  a  knife  and  there  is  reason  to  suspect  the  pres- 
ence of  pus,  if  none  be  found  then  the  operator  should  at  once  be  on 
guard  against  syphilis  or  a  neoplasm. 

The  .r-rays  are  sometimes  exceedingly  helpful  in  disclosing  growths 
that  fill  the  cavity  of  the  sinus,  but  are  not  otherwise  discernible. 
The  history  of  the  case  and  the  Wassermann  test  facilitate  the  diag- 
nosis of  syphilis;  but  the  microscopic  findings  must  be  depended  upon 
to  determine  the  benign  or  malignant  character  of  the  growth. 


CHAPTER  X. 

DISEASES,  TUMORS,  AND  MALFORMATIONS  OF 
THE  TONGUE. 

DISEASES   OF    THE   TONGUE. 

Stomatitis. — All  forms  of  stomatitis  and  nearly  all  of  the  diseases 
of  the  mucous  membrane  which  have  been  described  (pp.  151  to 
191)  may  appear  primarily  upon  the  surface  of  the  tongue,  or  extend 
to  that  organ  from  other  parts  in  the  mouth. 

Glossitis. — Inflammation  of  the  tongue  may  be  acute  or  chronic, 
circumscribed  or  diffuse.  The  so-called  strawberry  tongue  of  scarlet 
fever  shows  how  the  appearance  of  the  tongue  may  become  an  impor- 
tant diagnostic  feature  in  exanthematous  fevers  and  other  infections. 
Superficial  glossitis  is  also  due  to  local  irritations,  the  effect  of  drugs, 
and  similar  influences,  and  is  evidenced  by  increased  redness  and 
swelling  of  the  papilke,  which  alter  the  surface  appearance  of  this 
organ. 

Furring  of  the  Tongue. — In  mild  catarrhal  conditions  of  the  mucous 
membrane  of  the  mouth  there  is  constant  desquamation  of  the  epithe- 
lium. When  this  takes  place  actively  the  cells  are  retained  upon  the 
surface,  portions  of  food  and  bacteria  cling  to  the  masses  of  desqua- 
mated cells,  and  the  result  is  the  whitish  or  brownish  furring  of  the 
tongue  that  is  common  to  many  diseases.  In  more  or  less  chronic 
cases  when  this  heaping  of  epithelial  cells  occurs  in  localized  areas, 
characteristic  irregular  patches  sometimes  result,  and  to  this  condition 
the  term  geograijhical  tongue  (see  Plate  XIX,  Fig.  2)  has  been  applied. 

Dr.  Kirk  has  shown  that  when  there  is  an  unusual  amount  of  lactic 
acid  in  the  salivary  secretion,  whether  caused  by  activity  of  the  lactic 
acid-producing  bacteria  concerned  in  the  process  of  dental  caries  or 
otherwise,  the  mucin  of  the  saliva  is  precipitated. 

Undoubtedly  the  increased  agglutinative  power  thus  acquired  by 
the  oral  secretions  is  in  a  large  measure  responsible  for  the  accumula- 
tions of  epithelial  cells,  bacteria,  and  food  products  upon  the  mucous 
membrane  and  particularly  upon  the  tongue  surface. 

Circumscribed  Glossitis. — Circuinscribed  glossitis  is  usually  due  to 
irritation  from  the  sharp  edges  of  a  tooth  or  root,  ill-fitting  or  other- 
wise imperfect  dental  plates  or  bridge-work,  accidental  biting  of  the 
tongue,  burns,  pipestems,  cigars,  the  continued  application  of  hot 
smoke;  the  nervous  mouth  habits,  however,  are  among  the  most 
important  causes,  as  they  are  likely  to  be  overlooked.  These  habits 
have  been  referred  to  in  connection  with  the  etiology  of  other  buccal 
affections. 

(531) 


532    DISEASES,  TUMORS,  AND  MALFORMATIONS  OF  TONGUE 

The  tongue  naturally  seeks  any  unusual  or  roughened  place  about 
the  teeth,  imperfect  interproximal  spaces  in  which  particles  of  food 
have  lodged  between  teeth,  or  the  spaces  occasioned  by  loss,  and  this 
may  easily  become  a  habit  leading  to  both  acute  and  chronic  condi- 
tions. 

Circumscribed  lingual  inflammatory  processes  may  result  in  local 
degenerative  conditions  with  hypertrophy  or  induration,  or  if  super- 
ficial,  an  ulcer  may  be  formed.  When  the  affection  penetrates  more 
deeply,  a  localized  abscess  sometimes  results.  These  do  not  differ 
materially  from  other  abscesses,  except  when  they  cause  general 
glossitis. 

The  pathology,  symptoms  and  treatment  of  these  affections  closely 
resemble  those  in  similar  conditions  in  other  tissues. 

Chronic  Glossitis. — When  glossitis,  whether  superficial  or  circum- 
scribed, becomes  chronic,  structural  changes  may  take  place,  which 
are  quite  similar  to  those  of  any  chronic  inflammatory  process.  When 
caused  by  specific  forms  of  infection  the  characteristic  lesions  appear. 
Malignant  tumors  are  prone  to  develop  at  the  site  of  such  chronic 
inflammations.  These  are  often  difficult  to  differentiate  from  benign 
affections.  They  usually  require  the  aid  of  a  microscope  for  diagnosis, 
but  certain  forms  are  occasionally  so  distinctive  that  no  confirmatory 
evidence  is  required  (Plate  XIX,  Fig.  3). 

Syphilis. — In  syphilis  (Plate  III,  Fig.  1)  the  primary  sore  is  found 
upon  the  tongue  in  a  large  proportion  of  cases,  and  secondary  lesions 
are  also  frequent,  but  leukoplakia  (Plate  VII,  Fig.  2),  giunma,  and 
the  indurated  scar  tissue  following  healed  lesions  (Plate  III,  Fig. 
1)  are  not  only  of  common  occurrence  among  patients  affected  by 
this  disease,  but  are  often  particularly  difficult  to  differentiate  in 
diagnosis  from  neoplasms,  tubercular  lesions  (Plate  XIX,  Fig.  1), 
and  the  results  of  inflammatory  affections  of  other  origin  (see  Syphilis, 
p.  107). 

Leukoplakia  (Plate  VII,  Fig.  2).— This,  it  is  admitted,  may  or 
may  not  be  syphilitic.  Tubercular  affections  are  less  frequent,  but, 
as  may  be  seen  from  examination  of  the  illustration  shown  in  Plate 
XIX,  Fig.  1,  can  sometimes  only  be  diagnosticated  by  discovery  of 
the  bacillus,  or  recognition  of  the  disease  by  methods  such  as  have 
been  set  forth  in  the  description  of  this  affection  (p.  181). 

This  is  also  true  of  syphilis,  and  the  methods  indicated  for  diag- 
nosis of  the  disease  (p.  107)  must  be  depended  upon  for  its  recognition 
rather  than  the  appearance  of  the  lesions. 

Diagnosis. — Diagnosis  is  the  all-important  feature,  because  early 
correction  may  often  prevent  the  development  of  serious  local  con- 
ditions, and  by  leading  to  the  institution  of  remedial  measures  when 
general  diseases  are  involved,  much  additional  benefit  may  ensue  for 
the  reason  that  these  might  not  otherwise  be  recognized. 

Dentists  should  make  it  a  rule  to  inspect  carefully  the  tongue  and 
tooth  surfaces  of  all  patients.     Thickened  or  irritated  areas  upon  the 


PLATE   XIX 


Tubercular  Cicatricial   Destruction  of  the  Tongue. 

FIO.     2 


Geographical  Tongue. 
Fia.  8 


Glossitis. 


DISEASES  OF  THE  TONGUE  533 

tongue  should  receive  immediate  attention.  Any  rough,  sharp,  or 
improperly  shaped  tooth  surface,  diseased  roots  or  teeth,  or  imperfect 
dental  work  should  be  removed,  smoothed  or  otherwise  corrected. 

Every  case  in  which  there  are  lesions  that  cannot  be  accounted 
for  should  without  delay  receive  the  benefit  of  all  modern  diagnostic 
aids,  to  determine,  if  possible,  the  real  cause. 

Physicians  should  be  on  the  lookout  for  causes  of  local  irritation, 
and  refer  such  cases,  with  clearly  defined  directions,  to  a  competent 
dentist. 

Treatment. — The  treatment  of  all  of  the  foregoing  forms  of  glossitis 
consists  in  removal  of  the  cause  of  irritation,  local  applications  to  relieve 
the  lesions,  and  attention  to  general  underlying  factors  if  necessary. 

Phlegmonous  Glossitis. — ^\hen  glossitis  becomes  diffuse  and  affects 
interstitial  structures  .(interstitial  glossitis),  it  may  be  associated  with 
the  production  of  an  excess  of  connecti\e  tissue,  or  acute  parenchym- 
atous inflammation  may  result  (parenchymatous  glossitis);  suppu- 
ration may  follow  and  then  the  condition  is  kno-^ii  as  phlegmonous 
glossitis. 

Etiology.^ — This  afiection  may  result  from  extension  of  the  cir- 
cumscribed inflammatory  conditions  of  the  tongue,  caused  by  local 
irritation,  or  infection.  It  may,  on  the  other  hand,  be  secondary  to 
phlegmonous  processes  in  the  region  of  the  palatal  tonsils,  or  to  Lud- 
wig's  angina  or  other  inflammatory  lesions  affecting  the  floor  of  the 
mouth  and  surrounding  parts. 

Erysipelas. — This  disease  is  a  somewhat  rare  but  \evy  serious  cause 
of  phlegmonous  glossitis.  Although  the  mucosa  and  the  uppermost 
layer  of  the  submucosa  are  principally  affected,  sometimes  excessive 
swelling  of  the  tongue  is  caused,  and  there  is  danger  because  of  the 
likelihood  of  edema  of  the  glottis. 

Foreign  Bodies. — Fish-bones  and  substances  of  this  nature  are 
not  infrequently  forced  into  the  tongue,  but,  contrary  to  expectation, 
these  do  not  often  cause  phlegmonous  glossitis. 

W.  ^Murray^  reports  that  f  x  f  x  J  inch  of  a  vulcanite  pipestem 
remained  in  the  mouth  of  one  of  his  patients  eight  months  before 
being  discovered. 

One  of  the  author's  patients,  who  had  previously  been  subjected 
to  the  ill-advised  use  of  cocain  with  electrolysis  for  the  extraction 
of  a  tooth  late  one  afternoon,  had  swelling  of  the  tongue  during  the 
same  night  that  almost  caused  fatal  suffocation,  which  was  avoided 
only  by  the  most  energetic  treatment. 

Symptoms.^In  glossitis  chiefly  confined  to  the  preepiglottic  region, 
the  situation  in  which  local  irritations  are  usually  first  manifested, 
the  symptoms  are  those  of  an  acute  angina.  There  is  difficulty  in 
swaflowing,  soreness,  perhaps  pain,  and  much  discomfort,  but  no 
serious  danger  unless  the  root  of  the  tongue  becomes  involved,    "\^hen 

1  British  Med.  Jour.,  January  1,  1910. 


534     DISEASES,  TUMORS.  AND  MALFORMATIONS  OF  TONGUE 

this  occurs,  the  swelling  may  be  confined  to  one  side  or  include  the  entire 
or^an.  The  tongue  is  distended  to  such  an  extent  that  it  becomes 
too  large  for  the  mouth,  and  is  sometimes  forced  between  the  teeth. 
The  resulting  pressure  is  so  great  that  the  floor  of  the  mouth  is  forced 
downward,  the  structures  of  the  pharynx  backward,  and  the  soft 
palate  upward.  Respiration  is  thus  mechanically  interfered  with  even 
though  there  may  not  be  an  edema  of  the  glottis. 

Under  these  circumstances  patients  are  obliged  to  bend  their  heads 
back  as  far  as  possible  in  order  that  air  may  be  drawn  through  the 
nose  over  the  back  of  the  tongue.  The  characteristic  position  is 
shown  in  Fig.  88,  p.  169.  The  face  is  congested.  ■Movements  of 
the  tongue  are  so  curtailed  that  speech  is  impossible,  and  mastication 
and  swallowing  almost  or  entirely  prevented.  The  saliva  dribbles 
from  the  mouth,  and  the  pressure  of  the  tongue  against  the  teeth 
causes  soreness  of  its  borders  and  adds  materially  to  the  general  dis- 
tress. In  the  region  of  the  circumvallate  papillae  the  tongue  becomes 
hard  and  board-like,  and  this  condition  in  most  cases  also  extends  to 
the  submental  and  hyoid  regions. 

Treatment. — There  is  danger  of  asphArxia  and  inspiration  pneumonia 
from  the  uncontrolled  saliva  which  cannot  be  swallowed  and  has  a 
tendency  to  overflow  into  the  respiratory  channels.  Being  filled  with 
pyogenic  microorganisms,  bronchial  and  pneumonic  affections  are 
natural  consequences.  The  toxic  and  septic  influences  common  to 
all  virulent  infections  are  also  to  be  feared. 

Treatment  must  therefore  be  prompt  and  energetic  in  order  to  be 
effective.  A  deep  incision  with  the  point  of  a  curved,  narrow-bladed 
bistoury  passed  back  over  the  tongue,  under  guard  of  a  finger,  intro- 
duced just  behind  the  circumvallate  papilla?,  and  carried  forward 
through  the  body  of  the  tongue,  gives  free  blood-letting  and  an  exit 
for  serum,  or  pus  if  present.  This  usually  allows  the  excessive  swel- 
ling to  subside  sufficiently,  at  least,  to  give  a  measure  of  immediate 
relief. 

If  the  hemorrhage  is  excessive  the  wound  is  packed  with  gauze, 
otherwise  it  is  allowed  to  remain  open  until  the  swelling  has  subsided 
and  then  closed  with  sutures  if  necessary.  Mildly  antiseptic  astrin- 
gent mouth  washes  should  be  used  constantly  to  reduce  the  inflam- 
mation and  guard  against  fm-ther  infection. 

Symptoms  of  suffocation  require  an  immediate  tracheotomy,  after 
which  other  measures  for  controlling  the  swelling  may  be  resorted  to. 

In  less  severe  cases,  or  whenever  the  exigencies  of  the  case  permit, 
irrigation  with  hot  solutions,  the  face  being  turned  upon  one  side 
to  allow  the  fluid  to  run  out  freely  and  to  flow  continuously  for  a 
sufficient  time,  is  sometimes  beneficial  at  the  onset  of  the  affection, 
and  may  abort  the  progress  of  the  inflammation  sufficiently  to  make 
more  radical  measures  unnecessary. 

Kiinmiell  reconmiends  for  cases  in  which  there  is  a  marked  indu- 
ration in  the  submental  region,  with  the  skm  red  and  edematous, 


DISEASES  OF  THE  TONGUE  535 

a  deep  incision  extending  between  the  genioglossi  muscles  and  the 
wound,  and  enlarged  in  the  substance  of  the  tongue  by  blunt  dissection. 
He  states  that: 

"The  evacuation  of  the  foul-smelling  pus  always  produces  an  imme- 
diate amelioration  of  the  pain  and  dyspnea.  This  incision  has  the 
advantage,  moreover,  of  a  complete  evacuation,  without  the  danger 
of  pus  and  blood  finding  their  way  into  the  air  passages."^ 

Gangrene  of  the  Tongue. — Gangrene  of  the  tongue  may  be  due  to 
pressure  against  the  teeth  when  it  is  swollen,  or  to  vascular  disturb- 
ance incident  to  a  phlegmonous  glossitis;  to  severe  injuries,  burns, 
noma,  Ludwig's  angina,  and  other  destructive  processes  which  occur 
in  the  course  of  typhoid,  puerperal,  and  other  infections. 

Pseudomembranous  Glossitis. — This  is  a  rare  affection  accom- 
panied by  marked  .exfoliation.  Sometimes  casts  of  the  tongue  are 
exfoliated.  The  diphtheria  bacillus,  streptococci,  and  sometimes 
pneumococci  have  been  knowTi  to  give  rise  to  this  condition. 

Treatment. — Local  measures  are  of  little  avail.  Antistreptococcic 
seriun  treatment  and  helpful  measures  of  a  general  natiu-e  must  be 
relied  upon. 

Psoriasis. — Psoriasis  of  the  tongue  is  a  term  used  by  some  authors 
synon\Tnously  with  leukoplakia  buccalis.^ 

Nigrities  Linguae. — This  disease,  also  known  as  black  tongue,  is  a 
form  of  hypertrophy  of  the  papillae  of  the  tongue  with  pigmentation. 

Etiology. — -The  cause  is  not  known.  Dr.  Kirk,  of  Philadelphia,  made 
careful  bacterial  examinations  in  an  interesting  case  that  came  under 
his  care,  but  without  definite  identification  of  a  specific  bacterium. 

Symptoms. — The  dorsiun  becomes  covered  with  a  hair-like  coating, 
dark  brown  or  quite  black  in  color. 

Treatment.^ — The  only  treatment  that  can  be  satisfactorily  employed 
without  exact  knowledge  of  the  cause  is  a  thorough  cleansing  of  the 
tongue  surface  and  of  the  mouth  generally,  the  use  of  dioxogen  to 
aid  in  freeing  the  mucous  membrane  surface  from  its  coating,  and 
general  care  of  the  health  of  the  individual. 

Nervous  Affections  of  the  Tongue. — Atrophy  of  the  muscles  of  the 
tongue  results  from  bulbar  palsy  and  other  forms  of  muscular  dystrophy. 

Smooth  atrophy  of  the  root  of  the  tongue  is  characterized  by  disappear- 
ance of  the  follicles,  thinning  of  the  epithelium,  and  later  by  muscular 
atrophy  and  occlusion  of  the  mucous  glands.  Some  ^\Titers  have 
claimed  that  this  is  a  symptom  of  sj-philis,  but  it  is  now  known  to 
occur  in  other  diseases  such  as  tuberculosis,  senile  changes,  and  other 
degenerative  processes. 

Tremor  of  the  tongue  is  evidence  of  nervous  disease,  as  is  also  the 
deviation  of  the  tongue  to  one  side,  when  protruded  from  the  mouth. 

Hemiglossitis. — A  transitory,  unilateral  swelling  of  the  tongue 
believed  to  be  of  nervous  origin. 

1  Von  Bergmann:  System  of  Practical  Surgery,  i,  839,  840. 

2  Dorland:  American  Medical  Dictionary. 


536     DISEASES,  TUMORS,  AND  MALFORMATIONS  OF  TONGUE 

Symptoms. — ^The  tongue  becomes  enlarged  upon  one  side.  During 
the  early  stages  there  is  acute  pain  and  high  fever,  which  usually 
subside  by  the  end  of  the  first  day  and  the  swelling  after  three  or  four 
days. 

Treatment. — Palliative  treatment  may  give  a  little  comfort,  but  the 
afl'ection  usually  runs  its  course.  Nerve  tonics,  hygiene,  and  similar 
aids  to  general  nerve  resistance  are  indicated. 

Foot-and-mouth  Disease. — Vesicles  and  painful  swelling  of  the 
tongue  are  prominent  symptoms.  In  such  cases  diagnosis  and  treat- 
ment of  this  afl['ection  as  described  (p.  161)  are  required. 

Actinomycosis  (p.  129),  Glanders  (p.  134),  and  Leprosy  (p.  139). — 
These  have  tongue  lesions  which  are  included  in  the  description  of 
these  diseases. 

Riga's  Disease. — This  disease  is  a  sublingual  growth  in  infants. 
It  is  essentially  an  ulcerative  or  pseudomembranous  lesion  on  the 
under  surface  of  the  tongue  which  involves  the  frenum. 

Etiology.^It  is  undoubtedly  caused  by  infection  which  is  presum- 
abh'  influenced  by  difficulty  in  eruption  of  the  lower  incisor  teeth. 

Symptoms. — For  the  greater  part  it  affects  nursing  infants  and 
begins  b}'  an  ulcerative  or  necrotic  process,  which  is  followed  by  a 
granulomatous  growth  that  sometimes  closely  resembles  papilloma  or 
fibroma. 

Treatment. — On  account  of  the  susceptibility  of  infants,  the  local 
treatment  must  be  such  as  can  safely  be  applied  to  inflammation  in 
an  infant's  mouth. 

Careful  examination  of  the  erupting  teeth  should  be  made  and 
inflammatory  processes  relieved  by  incisions  through  the  gum  over 
their  crowns  if  necessary.  If  digestive  disturbance  is  evident,  cor- 
rective measures  must  be  employed. 

Myositis. — The  various  forms  of  myositis  may  affect  the  muscles  of 
the  tongue  the  same  as  other  muscles.  Acute  conditions  are  apparent 
in  myositis.  The  form  of  acute  poliomyositis,  called  dermato-mucoso- 
myositis,  sometimes  attacks  the  tongue,  and  may  be  associated  with 
stomatitis  with  or  without  ulceration  or  angina. 

Etiology.— This  is  believed  to  be  caused  by  infection,  but  the  fact 
that  the  condition  is  sometimes  accompanied  by  polyneuritis  lends 
color  to  the  belief  that  nervous  conditions  may  also  be  important  in 
its  causation. 

Symptoms. — The  muscles  are  swollen,  red  or  pale  yellow,  some- 
times streaked  with  gray  or  reddish  striae.  In  consistency  they  may 
be  firm  or  soft  and  boggy,  and  are  sometimes  accompanied  by  hemor- 
rhages. 

TUMORS   OF   THE    TONGUE. 

Cysts. — Varieties. — Betention  Cysts.— The  retention  cysts  sometimes 
found  at  the  tip  of  the  tongue  are  caused  by  occlusion  of  the  glands 
of  Blandin-Nuhn.     For  further  description  see  p.  436. 


TUMORS  OF  THE  TONGUE 


537 


Hydatid,  Echinococcus  and  Cysticerctis  Cysts.- — Hydatid  cysts, 
echinococcus  cysts,  and  all  forms  of  cysticercus  cysts,  caused  by  the 
scolex  or  larvse  of  tapeworms,  have  in  rare  instances  been  found. 
They  resemble  mucous  cysts  in  roundness  of  form,  but  are  harder, 
less  transparent,  can  be  moved  about  with  the  finger  and  are  always 
multiple.  They  may  be  distinguished  from  mucous  cysts  by  these 
features  (see  p.  435). 

Dermoid  cysts  are  sometimes  situated  between  the  genioglossi  and 
extend  into  the  body  of  the  tongue  (Fig.  333).  The  detailed  consider- 
ation of  dermoids  may  be  found  on  p.  442, 


Fig.  333. — Dermoid  (ad-hyoid)  cyst  at  base  of  tongue.     (Marchant.) 


Treatment. — The  removal  of  a  dermoid  cyst  at  the  base  of  the 
tongue,  as  shown  in  Fig.  333,  requires  an  incision  in  the  median  line 
from  the  chin  to  the  hyoid  bone.  Division  of  the  tissues  is  made  down 
to  and  between  the  geniohyoglossi  muscle  and  retraction  effected  to 
expose  the  tumor,  which  is  freed  by  blunt  dissection.  This  is  com- 
paratively easy  to  accomplish  unless  the  cyst  walls  are  bound  by 
inflammatory  adhesions.  Great  care  must  be  used  to  avoid,  if  possible, 
rupture  of  the  cyst  wall.  After  removal  of  the  cyst  the  wound  is 
packed  with  gauze,  if  necessary  to  control  hemorrhage.  Otherwise 
drainage  is  inserted  and  the  wounds  closed. 

Cysts  at  the  Base  of  Tongue.— Cysts  at  the  base  of  the  tongue  are 
sometimes  found  occupying  the  sinus  pyriformis. 


538     DISEASES,   TUMORS,  AND  MALFORMATIONS  OF  TONGUE 


Etiology. — These  cysts  are  apparently  caused  by  remains  of  the 
fetal  thyroglossal  duct. 

Symptoms. — They  seldom  give  much  disturbance.  The  symptoms 
are  usually  quite  similar  to  hypertrophy  of  the  lingual  tonsils.  Reflex 
cough  and  a  sense  of  discomfort  such  as  might  be  caused  by  any 
foreign  substance  in  the  throat  may  occasion  annoyance  (Fig.  334). 

Diagnosis. — A  laryngeal  mirror  facilitates  diagnosis. 

Treatment. — Incision  and  cauterization  will  usually  accomplish  their 
removal. 


Fig.  334. — Thyroglossal  cyst.      (Brewer.) 

A.  S.  Taylor^  reports  the  following  interesting  case  of  cyst  of  the 
thyroglossal  duct: 

"A  man,  aged  forty  years,  for  three  years  had  had  a  cyst  just 
above  the  larynx,  which  gradually  became  more  annoying,  so  he  had 
to  have  it  removed.  A  transverse  incision  was  made  over  the  cyst, 
which  extended  from  the  upper  border  of  the  larynx  to  the  under 
surface  of  the  hyoid.  From  this  point  a  small  fistulous  opening 
penetrated  the  hyoid  and  extended  to  the  base  of  the  tongue.  The 
growth  was  shaped  somewhat  like  an  Indian  club  above  the  hyoid 
and  ran  up  to  the  dorsum  of  the  tongue.  The  cyst  below  the  hyoid 
had  pushed  the  thyrohyoid  membrane  back  until  it  almost  touched 
the  wall  of  the  pharynx.  Although  the  patient  is  a  singer,  this  has 
not  interfered  with  his  voice.  The  cyst  was  entirely  removed:  no 
drainage  was  used;  primary  union." 

Lipoma. — Lipoma  of  the  tongue  is  exceedingly  rare,  although  such 
tumors  have  been  found  in  this  situation  more  frequently  than  in 
other  parts  of  the  mouth.  It  is  believed  that  in  a  considerable  por- 
tion of  these  cases  the  condition  is  congenital. 

1  Ann.  Surg.,  February,  1910. 


TUMORS  OF  THE  TONGUE  539 

Papilloma  and  Fibroma  (see  pp.  450  and  460). — These  tumors  are 
sometimes  fouiicl  upon  the  dorsum  of  the  tongue.  As  they  are  painless 
and  of  slow  growth,  their  chief  significance  lies  in  the  likelihood  of  their 
becoming  malignant,  or  in  the  course  of  slow  development  giving 
more  or  less  serious  inconvenience.  Their  removal  when  required 
may  usually  be  easily  effected,  and  the  same  rules  apply  as  for  the 
treatment  of  similar  growths  in  other  parts. 

Adenoma. — For  general  description,  see  p.  452. 

Lingual  Goiter. — So-called  accessory  thyroids  at  the  base  of  the 
tongue  are  tumors  consisting  of  tissue  derived  from  the  thyroid  gland, 
which  until  recently  have  been  described  as  adenomata. 

The  suprahyoid  glands  are  remnants  of  the  imperfect  middle  lobe 
of  the  thyroid  gland.  They  are  found  embedded  in  the  substance 
of  the  tongue  where  the  thyroglossal  duct  empties  at  the  foramen 
cecmii.  The  accessory  thyroids  usually  found  in  females  are  situated 
farther  down  near  the  hyoid  bone. 

Ectopic  or  supernumerary  thyroids  may  also  be  found  in  the  base 
of  the  tongue. 

These  timiors  are  now  recognized  as  aberrant  goiters. 

Etiology. — They  originate  from  the  remnants  of  the  median  thyroid 
outgrowth  or  an  ectopic  tlm'oid  embodied  in  the  base  of  the  tongue. 
Histologically  they  are  similar  to  other  varieties  of  goiter. 

Symptoms. — These  strumous  growths  are  situated  in  the  median 
line.  They  form  a  round  sweUing  behind  the  circumvallate  papillse; 
are  covered  with  smooth  mucosa  or  have  slightly  notched  surfaces; 
are  elastic  and  quite  vascular;  numerous  veins  may  be  seen  corn-sing 
over  the  surface  of  the  thin  mucosa;  they  seldom  or  never  ulcerate, 
but  do  often  cause  hemorrhages;  theu'  growth  may  be  so  slow  that  the 
swelling  may  pass  unnoticed;  it  may  be  continuous  or  progress  to  a 
certain  point  and  become  stationary;  or  may  change  to  an  acute 
condition  in  which  increase  in  size  takes  place  rapidly.  These  tumors 
are  painless,  but  may  become  so  large  as  to  interfere  with  speech, 
deglutition,  and  respiration. 

According  to  ]M.  Leulier,i  "JNIj-xedema  seems  to  be  unusually  fre- 
quent in  these  goiters,  and  assumes  all  forms  from  idiocy  to  early 
perceptible  s^inptoms." 

Diagnosis. — Differentiation  must  be  made  from  malignant  disease 
of  the  glands.  Thyroglossal  duct  cysts  from  dermoids,  ranula,  lingual 
tonsils,  and  angiomas.  Slo^^^less  of  growth  usually  excludes  malig- 
nancy. Angioma  is  more  spongy,  more  irregular  in  outline,  of  a  purple 
color,  and  usually  showing  venous  extension  to  one  of  the  lateral 
pharyngeal  areas. 

Treatment. — The  extirpation  of  these  tumors  is  required  if  the 
functional  disturbance  is  sufficient  to  make  their  removal  miperative. 
If  a  thAToid  is  normal,  complete  removal  is  indicated.     When  the 

1  These  de  Paris,  quoted  in  Presse  Medicale,  May  18,  1918. 


540     DISEASES,  TUMORS,  AND  MALFORMATIONS  OF  TONGUE 

th}Toid  is  abnormal  and  there  are  signs  of  myxedema,  a  portion  of 
the  thyroid  tissue  of  the  tumor  should  be  left,  to  prevent  cachexia. 

The  removal  of  these  growths  may  be  performed  through  the  mouth 
after  preliminary  tracheotomy  and  tapping  of  the  trachea.  The 
tongue  is  drawn  forward  with  ligatures  and  the  growth  removed. 
Wolf  recommends  temporary  resection  of  the  maxilla  for  infants. 
It  would  seem  as  though  this  might  be  the  safer  procedure  in  cases 
with  tendency  to  severe  hemorrhage. 

Charles  Mayo'  gives  the  following  operative  description: 

"In  the  enucleation  of  lingual  thyroids  the  tongue  and  pharyngeal 
areas  are  cocainized,  the  patient  anesthetized  with  ether  and  a  rapid 
operation  made  while  the  tongue  is  held  in  extreme  tension.  The 
free  hemorrhage  is  controlled  by  deep  sutures.  In  very  extensive 
superior  lingual  goiter  it  may  be  advisable  occasionally  to  ligate  the 
lingual  arteries  and  make  a  laryngotomy  as  a  preliminary  procedure. 
It  will  rarely  be  necessary  to  divide  and  separate  the  lower  jaw. 

"While  the  operations  for  the  removal  of  lingual  thyroids  through 
the  mouth  have  been  quite  bloody,  they  have  been  successful;  prac- 
tically no  fatalities  have  been  reported.  Although  there  have  been 
approximately  but  50  cases  recorded,  undoubtedly  there  have  been 
many  others  in  which  patients  have  been  operated  on." 

Hemangioma. — ^These  growths  are  congenital,  although  they  may 
not  be  noticed  until  enlargement  calls  attention  to  their  existence. 

Varieties. — Simple  angiomata  appear  upon  the  tongue  as  bluish-red, 
elevated  patches  of  variable  size,  usually  about  as  large  as  a  pea.  They 
may  be  single  or  multiple. 

Cavernous  angioma  presents  dark  blue  ridges  or  masses  above  the 
surface  of  the  mucous  membrane,  and  sinks  deeply  into  the  submucous 
tissues.  Under  pressure  the  blood  in  these  tumors  recedes  and  imme- 
diately returns  when  pressure  is  removed.  They  show  more  or  less 
increase  in  size  when  the  patient  stoops  and  are  again  smaller  when 
the  head  is  erect. 

Cavernous  angioma  sometimes  invades  surrounding  tissue  so  exces- 
sively that  almost  the  entire  tongue  may  become  involved.  Hemor- 
rhages may  occur  as  the  vessel  walls  become  thin  and  lose  resistance. 

Tieatment. — Small  circumscribed  angiomata  require  no  treatment 
other  than  cauterization,  and  ordinarily  may  even  be  allowed  to  remain 
without  serious  disadvantage. 

Cavernous  angiomata  when  very  small  may  be  excised  under  cocaine 
anesthesia,  but  tissue  outside  of  the  distended  vessels  should  be  included 
to  avoid  excessive  hemorrhage.  A  somewhat  larger  angioma  may  be 
incised,  and  the  spongy  mass  thoroughly  curetted.  To  do  this  the 
affected  tongue  area  is  cocainized  and  the  tongue  clamped  to  prevent 
excessive  bleeding.  After  pressure  is  removed,  bleeding  vessels  are 
ligated.     In  operations  upon  very  large  cavernous  angiomata  of  the 

1  Jour.  Am.  Med.  Assn.,  September  2,  1911,  p.  786. 


TUMORS  OF  THE  TONGUE 


541 


tongue  every  precaution  against  the  ill  results  of  hemorrhage  must  be 
taken.  The  pharynx  must  be  packed  with  gauze  and  other  precautions 
that  have  veen  described  for  the  management  of  hemorrhage  from 
mouth  operations  observed.  Ligation  of  the  lingual  arteries  or  even 
the  external  maxillary  arteries  may  be  necessary. 

Thiersch's  method  of  ignipuncture  has  met  with  considerable  success. 
He  forces  a  Paquelin  cautery  into  the  tumor  at  several  points,  thus 
creating  an  inflammatory  action  which  tends  to  cause  an  obliteration 
of  the  growth. 

Lymphangioma. — Lymphangiectases  are  sometimes  found  on  the 
end  of  the  tongue.  They  contain  a  viscid  fluid,  may  attain  consider- 
able size,  and  usually  have  a  base  made  up  of  smaller  cysts. 


Fig.  335. — Lymphangioma  of  the  tongue — macroglossia.      (Westmoreland.) 


Nodular  lymphcuigiomata  are  small,  isolated,  hemispherical  elevations 
scattered  over  the  base  and  back  of  the  tongue,  singly  or  in  groups. 
The  roughened  surface  is  covered  with  minute  vesicles  that  contain 
watery,  turbid,  or  bloody  fluid.  These  lesions  have  a  firm  base  which 
has  been  shown  to  be  an  inflammatory  product  caused  by  temporary 
periods,  during  which  the  growths  are  slightly  inflamed  and  enlarged. 
The  induration  remains  as  a  permanent  result. 

One  of  the  author's  cases,  that  of  a  little  boy,  aged  about  three  years, 
showed  several  small  lymphangiomata  along  the  border  and  anterior 
third  of  the  tongue,  and  although  it  did  not  seem  likely  that  the  small 
red  elevations  upon  the  tongue  surface  could  by  any  possibility  inter- 
fere with  speech,  yet  the  child  could  only  utter  a  few  words,  and  these 
very  indistinctly. 

Treatment. — Deep  cauterization  under  local  anesthesia,  repeated  at 
intervals,  if  necessary,  will  cause  a  disappearance  of  these  gro^i;hs 


542    DISEASES,  TUMORS,  AND  MALFORMATIONS  OF  TONGUE 

in  the  course  of  time.  (See  Ljinphangioma  and  Macroglossia,  pp.  464 
and  543.) 

True  Cavernous  Lymphangioma. — This  may  lead  to  enlargement 
of  the  tongue,  which  is  one  form  of  macroglossia.  The  condition 
exists  at  birth,  but  is  more  noticeable  when  the  tongue  has  become 
so  large  that  it  projects  beyond  the  teeth  and  lips.  Fig.  335  shows 
a  typical  case  of  l>7nphangioma  of  the  tongue. 

Treatment. — The  excision  of  wedge-shaped  pieces  to  reduce  the  size 
of  the  tongue,  and  this  repeated  at  intervals,  with  the  removal  of  a 
portion  of  the  tip  also,  if  required,  will  overcome  the  trouble  in  the 
course  of  time. 

Endothelioma. — This  tumor  rarely  affects  the  tongue. 

Sarcoma. — Sarcoma  is  found  more  frequently  in  this  situation,  but 
is  not  common. 

Carcinoma.— Carcinoma  is  unfortunately  very  prevalent  in  persons 
of  adxanced  years.  The  diagnosis  and  operative  treatment  of  these 
growths  are  described  under  their  several  headings,  page  474,  etc. 

MALFORMATIONS  OF  THE  TONGUE. 

Aglossia  (Congenital  Absence  of  the.  Tongue). — This  deformity  is 
never  found  with  malformations  of  the  face  alone.  It  is  assumed  that, 
in  common  with  congenital  tongue  defects,  this  is  caused  by  the  for- 
mation of  amniotic  bands  and  adhesions  which  restrain  and  interfere 
with  the  development  of  the  embryonal  fissures. 

Bifid  Tongue. — Agnathia,  the  congenital  absence  of  .the  lower  jaw, 
is  always  accompanied  by  absence  of  the  tongue  or  bifid  tongue. 
Bifid  tongue  has  been  found  with  a  case  of  divided  lower  jaw.  The 
tongue  is  sometimes  divided  as  the  result  of  accident  or  disease,  notice- 
ably sclerotic  syphilitic  glossitis.  The  natural  appearance  of  the 
mucous  membrane  in  the  former  condition  as  distinguished  from  the 
cicatrized  surface  of  the  latter,  together  with  the  history  of  the  case, 
makes  diagnosis  comparati\'ely  simple. 

Lobulated  Tongue.— Congenital  clefts  in  tongues  sometimes  take 
the  form  of  lobes  projecting  out  from  the  body  of  the  tongue.  An 
example  of  this  is  shown  in  Fig.  336,  taken  from  the  photograph  of 
the  tongue  of  a  little  girl,  aged  five  years,  who  came  under  the  author's 
care  for  treatment  of  congenital  cleft  palate.  It  was  difficult  to  deter- 
mine to  what  extent  the  tongue  defect  was  responsible  for  her  inability 
to  speak,  because  of  associated  nasal  and  palatal  defects. 

Microglossia. — A  congenital  condition  in  which  the  tongue  is  small 
enough  to  warrant  this  descriptive  term  is  rare,  but  there  are  cases  in 
which  the  tongue  is  so  small  as  to  appear  to  be  almost  entirely  absent. 

A  newly  born  infant  that  was  brought  to  the  author  for  treatment 
had  a  tongue  so  small  that  its  tip  was  barely  discernible  when  the 
mouth  was  opened. 

The  base  seemed  fairly  large,  and  in  the  belief  that  some  congenital 


MALFORMATIOXS  OF  THE  TONGUE 


543 


insufficient  development  of  the  glossopharyngei  muscles  or  adherent 
bands  of  tissue  might  be  holding  the  organ  back,  an  attempt  was  made 
to  cut  these  muscles  ^nd  draw  the  tongue  forward  to  fill  its  natural 
place.  It  was  found  to  be  impossible  to  benefit  the  child  by  surgical 
assistance. 

Macroglossia  (Megaloglossia)  (see  L\Tiiphangioma,  p.  464).  —  En- 
largement of  the  tongue  also  takes  place  in  acromegaly,  and  its  control 
is  subject  to  general  treatment  of  this  affection  as  described  (p.  542j  and 
such  operati\'e  procedures  as  may  be  required  to  give  relief. 


Fig.  336. — Lobulated  tongue.     Child,  aged  6ve  years. 


Long  Tongue. — Abnormally  long  tongues  sometimes  become  a 
menace  through  danger  of  their  being  swallowed.  Cases  have  been 
reported  in  which  sutl'ocation  has  occurred  from  this  cause.  Girod 
reports  a  case  in  which  the  tongue  could  be  extended  7  cm.  beyond 
the  line  of  the  incisor  teeth.  Naturally  only  the  exceedingly  long 
tongues  have  occasioned  sufficient  notice  to  be  reported;  but  the 
author  believes  that  in  certain  individual  t^'pes  a  long,  narrow  tongue 
resembling  the  tongue  of  a  dog  when  protruded  is  not  unusual;  and  in 
these  cases  there  is  very  likely  to  be  speech  difficulty. 

Lingua  Plicata  or  Dissecata. — This  is  a  congenital  condition  in  which 
the  tongue  is  moderateh-  enlarged  and  has  a  nimiber  of  longitudinal 
transverse  folds.  In  these  cases  there  is  absence  of  uniform  and  smooth 
surface,  although  the  mucous  membrane  appears  to  be  otherwise 
unchanged,  and  the  parench^-ma  retains  its  soft  character. 

Treatment  is  not  required  in  these  cases  unless  enlargement  of  the 
dental  arches  may  be  indicated  or  some  correction  required  because 
of  annoyance  to  the  patient. 

Ankyloglossia,  Lingua  Fraenata,  or  Tongue-tie. — This  is  caused  by 
a  large  and  anteriorly  displaced  frenum. 

Symptoms. — Attention  is  usually  called  to  the  trouble  in  infants, 
because  they  have  difficulty  in  sucking,  and  upon  examination  it  is 
found  that  the  tip  of  the  tongue  cannot  be  raised,  or  is  turned  do\\^lward 
when  the  tongue  is  protruded.  ^Mothers  and  even  attending  doctors 
often  overestimate  the  importance  of  this  condition.     In  most  cases 


544    DISEASES,  TUMORS,  AND  MALFORMATIONS  OF  TONGUE 

if  the  finger  can  be  introduced  beneath  the  tip  of  the  tongue  and 
that  organ  drawn  forward  over  the  alveolar  border  an  incision  is  not 
required,  and  should  not  be  made  unless  obviously  necessary. 

Ankyloglossia  in  greater  or  lesser  degree  is  sometimes  found  in  older 
persons,  and  in  these  cases  decision  as  to  the  best  procedure  is  some- 
times difficult,  as  indicated  by  descriptions  of  cases  which  follow. 

In  many  of  the  author's  cases  of  children  past  the  age  for  the  natural 
acquuement  of  speech,  and  even  adults,  the  difficulty  was  chiefly 
noticed  because  of  defective  speech.  Some  of  these  had  had  slight 
but  only  temporarily  effective  operations,  while  the  tongues  of  others 
were  bound  with  sufficient  tightness  to  interfere  with  taking  nourish- 
ment. If  there  were  no  other  bar  to  speech  progress  than  the  tongue- 
tie,  the  diagnosis  would  be  sunple,  but  in  many  instances  there  were 
indications  that  the  individual  was  to  some  extent  otherwise  defective. 
When  in  such  cases  there  was  a  more  or  less  considerable  ability  to 
move  the  tongue,  even  though  contraction  at  the  tip  during  protrusion 
showed  that  it  did  not  ha\'e  complete  freedom,  it  was  hard  to  say 
whether  defective  speech  was  due  to  one  or  the  other  of  the  following 
causes:  (1)  Entirely  to  ankyloglossia;  (2)  primarily  to  restriction  of 
the  tongue  and  secondarily  to  failure  of  development  of  the  speech 
centers;  (3)  to  inability  or  reluctance  to  make  the  necessary  effort  to 
acquire  speech,  because  of  the  impediment;  or  (4)  to  central  causes, 
which  would  by  no  means  be  improA'ed  through  any  sort  of  tongue 
operation. 

Treatment. — Cutting  of  the  frenmn  with  scissors  in  infants  is  a  very 
slight  operation;  and  usually  the  constant  movement  of  the  tongue 
may  be  depended  upon  to  prevent  the  parts  from  reuniting.  As 
already  indicated,  operative  interference  need  only  be  resorted  to 
when  there  is  absolute  indication  of  its  necessity. 

In  the  treatment  of  the  older  children  and  adults  the  operator  is 
confronted  with  the  embarrassing  possibility  of  performing  an  opera- 
tion which  will  not  be  a  benefit  if  the  speech  affection  be  due  to  some 
other  cause  than  the  tongue  condition.  In  these  cases,  especially  when 
imperfectly  treated  in  infancy,  there  is  sometunes  not  alone  the  actual 
frenum  to  be  dealt  with,  but  an  interweaving  of  muscular  or  cicatricial 
fibers  from  the  frenum  along  the  under  surface  of  the  tongue  to  the  tip, 
which  retracts  the  tip  of  the  tongue  during  protusion,  because  develop- 
ment along  this  surface  has  not  kept  pace  with  the  growth  of  other 
parts  of  the  organ.  In  such  cases  only  a  plastic  operation  which  will 
give  actual  increase  in  the  length  of  the  constricting  portion  of  the 
tongue  might  be  expected  to  give  sufficient  freedom  to  enable  the  tip 
of  the  tongue  to  be  readily  placed  in  the  positions  required  for  correct 
phonation. 

The  author's  custom  in  these  cases  is  to  direct  a  course  of  speech 
training  or  other  tongue  movement  for  the  purpose  of  demonstrating 
whether  the  inability  to  move  the  tongue  can  be  improved  by  training. 
If  the  general  intelligence  and  the  sense  of  hearing  are  such  as  to  permit 


MALFORMATIONS  OF  THE  TONGUE  545 

improvement  in  the  utterance  of  the  elementary  sounds  least  affected 
by  the  tongue  condition,  then  operative  procedures  are  indicated 
to  give  the  greatest  possible  freedom  in  the  use  of  the  tongue.  Other- 
wise the  surgeon  might  be  subjected  to  the  mortification  of  performing 
an  operation  which  could  not  be  beneficial. 

Adherent  Tongue. — This  term  is  applied  when  the  surface  of  the 
tongue  and  mouth  are  adherent  or  bound  by  bands  of  tissue.  Usually 
these  are  attached  to  the  edge  of  the  tongue  and  inner  surface  of  the 
lower  jaw.  Cases  have  been  reported  of  the  tongue  being  attached 
to  the  cheek.  In  infancy  these  bands  of  tissue  can  easily  be  broken 
with  the  fingers  or  with  a  dull,  suitably  shaped  instrument.  Occasion- 
ally a  cut  with  the  scissors  may  be  necessary.  Sometimes  the  anterior 
portion  of  the  tongue  must  be  dissected  free,  and  the  mucous  membrane 
infolded  in  suturing' the  wound  so  that  there  may  be  no  raw  surfaces 
in  contact  to  cause  recurrence  of  adhesions.  The  author  has  done 
this  recently  for  a  boy,  eight  years  old,  with  very  satisfactory  speech 
improvement. 


35 


CHAPTER    XI. 

NASAL  DEF0R:\IITIES  and  diseases  IX  RELATION  TO 

THE  ^LAXILL^. 

Etiology. — Developmental  Factors. — In  the  short  period  between  the 
fertihzatioii  of  the  human  ovum  and  the  fifth  to  the  seventh  week  of 
embryonic  life,  examination  of  the  sections  through  fetal  heads  dis- 
closes that  important  changes  have  already  taken  place.  Even  at  this 
early  stage  they  are  indicative  of  the  principles  that  must  govern  the 
treatment  in  correction  of  deformities  during  the  entire  period  of 
development  of  the  individual. 

"The  first  pharyngeal  arch  di^'ides  at  its  anterior  extremity  into 
two  parts — (a)  superior  and  inferior  maxillary  protuberance.  The 
latter  unites  very  early  to  its  fellow  of  the  opposite  side  to  form  the 
lower  jaw.  The  superior  maxillary  protuberances  are  displaced  out- 
ward and  unite  to  the  external  nasal  process;  from  this  part  are  devel- 
oped the  internal  plate  of  the  pterygoid  process,  the  palate  bone,  the 
superior  maxillary,  and  the  malar.  The  lateral  masses  of  the  ethmoid, 
the  OS  unguis,  and  nasal  bones  are  furnished  by  the  internal  nasal 
process.  The  rest  of  these  processes  on  either  side  are  united  by  a 
single  protuberance,  the  incisi\'e  tubercle,  from  which  the  intermaxillary 
bone  and  the  middle  of  the  upper  lip  are  formed,  and  according  to  some 
the  vomer.  "^ 

It  is  important  to  note  in  Fig.  337,  which  shows  a  section  through 
the  head  of  a  human  embryo  at  approximately  the  fifth  week,  that 
complete  coalescence  of  the  divisions  of  the  forming  face  and  mouth, 
resulting  from  progress  in  this  direction  of  the  palatine  lamellse  which 
are  given  ofT  from  the  maxillary  tuberosities  and  unite  to  form  the 
palate,  and  become  joined  to  the  incisive  bone  to  form  the  anterior 
part  of  the  mouth  and  upper  lip,  has  not  yet  been  completed.  If, 
therefore,  approximately  between  the  fifth  and  ninth  week  of  embry- 
onic life,  arrest  of  development  interferes,  a  union  in  this  particular 
region  will  not  take  place.  The  result  of  this  will  be  harelip,  cleft 
palate,  or  both  in  any  of  the  various  forms  in  which  these  maldevelop- 
ments  appear.  Reestablislmient  of  growth  in  its  natural  course  may 
and  usually  does  result  in  the  correct  formation  of  other  divisions 
of  the  head  and  face,  except  insofar  as  they  may  be  influenced  by  the 
effect  of  the  disarrangement  of  muscular  and  other  physiological  action 
through  the  deformity  which  has  now  become  established. 

'  Gray's  Anatomy. 
(546) 


ETIOLOGY  OF  NASAL  DEFORMITIES 


547 


Inspection  of  a  section  through  the  jaws  at  this  period,  under  higher 
magnification,  shows  the  epithehal  cord  which  marks  the  appearance 
of  the  first  indication  of  the  tooth  germs. 


Fig.  337. — Section  tlirough  the  head  of  a  human  embryo  at  approximately  the 
fifth  week.     (Latham.) 


Passing  in  succession  through  a  series  of  similar  sections  (Figs.  338 
and  339)  at  important  periods  until  birth,  we  find  that  in  the  absence 
of  arrest  or  other  interference  with  normal  growth  the  divisions  of  the 
palate  become  completely  united,  and  the  spaces  for  the  nares  so  much 
enlarged  that  they  occupy  a  very  considerable  portion  of  the  facial 
division.  The  palatal  surface  at  this  time  is  flat,  because  development 
of  the  alveolar  regions  has  not  yet  taken  place  to  any  considerable 
extent. 

As  the  tooth  follicles  increase  in  size,  and  their  eruption  thus  becomes 
more  completely  established,  some  of  them  are  situated  high  up  and 
just  outside  the  nares.  If  gro^vth  of  the  alveolar  ridges  takes  place  in 
natural  form,  uninipeded  by  any  factor  which  may  tend  to  restrict 
the  natural  size  of  the  arch,  the  developing  tooth  crowms,  the  germs  for 
both  temporary  and  permanent  sets  of  which  are  in  place  before  birth, 
can  pass  on  downward  and  outward  in  the  natural  course  of  their 
eruption.    In  this  way  they  make  it  possible  for  the  nares  and  their 


548        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 

dividing  septum,  as  well  as  turbinal  and  other  nasal   structures,  to 
assume  in  due  course  normal  form  and  proportions.     When  surgical, 


Fig.  338. — Section  through  the  head  of  an  embryo  at  approximately  the  twelfth   week. 


Fig.  339. — Section  through  the  head  of  a  human  embryo  at  approximately  the  twelfth 
week.  Developing  teeth  may  be  seen  high  up  at  each  side  of  the  nose  and  beneath  the 
tongue. 

mechanical,    developmental,    or    pathological    causes    interfere    with 
the  natural  expansion  of  the  arch,  which  represents  the  alveolar  ridge 


ETIOLOGY  OF  NASAL  DEFORMITIES  549 

and  later  the  dental  arch,  there  naturally  must  be  crowding  through 
lack  of  space,  and  the  tooth  crowns  cannot  assume  their  rightful  posi- 
tions in  relation  to  others  that  are  being  pushed  onward  by  the  forces 
which  cause  tooth  eruption.  The  first  efi'ect  of  pressure  from  crowding 
must  naturally  react  upon  regions  of  the  maxillae  in  which  the  tooth 
crowns  at  this  time  are  located.  Efl'ort  at  readjustment  takes  place 
in  the  direction  of  least  resistance.  This  must  be  in  the  direction  of 
the  nares,  and  causes  in  greater  or  lesser  degree  abnormality  of  form, 
which  is  chiefly  shown  by  their  restricted  size. 

The  second  efi'ect  is  overlapping  of  the  tooth  crowns,  evidenced 
by  their  eruption  on  the  outside  or  the  inside  of  the  true  line  of  the 
arch,  resulting  in  labial,  buccal,  or  lingual  occlusion.  When  the  pro- 
cess of  eruption  has  continued  to  a  point  where  the  cusps  of  the  teeth 
in  the  occluding  jaw  .can  come  in  contact  with  each  other,  the  muscular 
forces  of  jaw  movement,  acting  upon  the  inclined  planes  of  the  cusps 
and  the  crown  surfaces  of  the  teeth,  bring  into  play  the  active 
factors  through  which  regular  or  irregular  forms  of  dental  arches  are 
determined. 

Glancing  for  a  moment  upon  the  reverse  side  of  this  developmental 
picture,  we  must  recognize  that  from  the  moment  of  the  very  first 
respiration  at  birth,  one  of  the  most  potent  influences  upon  which  this 
jaw  expansion  and  development  depends  is  the  physiological  action  of 
correct  respiration.  Thus  we  have  established  backward  and  forward 
an  interrelation  of  growth  so  evenly  balanced  that  it  would  seem  to 
preclude  its  being  unusually  important  to  any  one  division  more  than 
the  other. 

Another  interestiitg  feature  in  the  embryonic  stages  is  noticed  in 
the  large  size  of  the  tongue  in  proportion  to  the  jaws.  This  is  impor- 
tant in  its  influence  upon  the  maxillary  ridges,  and  is  of  great  signi- 
ficance. Being  so  out  of  proportion  in  size,  arrest  in  the  growth  of  the 
jaws  consequently  fails  to  give  the  tongue  that  space  during  early 
childhood  which  will  enable  its  free  use  in  speech.  Such  children 
learn  to  speak  with  great  difficulty,  if  at  all,  or,  as  might  be  expected 
are  reluctant  to  make  the  unusual  effort  required  of  them  in  learning  to 
form  certain  words.  Thus  the  brain  cells,  directing  this  action,  do  not 
develop,  and  in  the  course  of  time  such  children  come  to  be  considered 
defective,  and  ultimately  really  become  so,  because  natural  progress 
of  the  speech  centers  is  arrested.  Undoubtedly  many  might  have  been 
at  least  approximately  normal  if  there  had  been  correction  at  a  suffi- 
ciently early  date.  In  summary  of  etiological  factors  pertaining  to 
these  affections  it  may  be  said  that:  ^.  fcij 

1.  Any  influence  which  can  affect  intra-uterine  growth,  and  this 
includes  arrest  of  development  from  any  cause,  be  it  hereditary, 
metabolic,  incidental,  or  accidental,  can  directly  bring  about  or  pre- 
dispose to  the  malformation  of  nose  and  mouth.  t  \ 

2.  Any  interference  with  continuous  and  complete  embryonic 
growth  will  manifest  itself  in  imperfect  form,  directly  due  to  the  arrested 


550       NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 

development  and  in  asjTimietrical  exaggerations  thereof,  including 
alteration  in  both  form  and  structure  by  the  imperfect  physiological 
action  of  the  immediately  affected  and  surrounding  parts. 

3.  After  birth  any  abnormal  muscular  activity,  whether  due  to  the 
unusual  stress  of  habit,  accident,  or  other  cause,  will  make  its  influence 
manifest  in  distortion  of  the  form  of  the  growing  parts. 

4.  With  obstruction  of  the  upper  air  passages  complete  s^^nmetrical 
formation  of  the  palate  and  upper  maxillary  arch  cannot,  as  a  rule,  be 
expected. 

Conversely,  any  factor  which  tends  to  contract  the  form  of  the 
palate  in  such  a  manner  as  to  bring  about  crowded  and  high-arched 
conditions  of  the  palatal  vault,  with  the  usually  attendant  saddle- 
shaped  narrow  dental  arch,  must  in  greater  or  lesser  degree  tend 
toward  contracted  nares,  deviated  nasal  septa,  and  commonly  associ- 
ated nasal  defects.  For  these  reasons  it  is  manifest  that  adenoids 
and  enlarged  tonsils,  whether  first  or  second  in  etiological  succession, 
are  always  and  invariably  contributing  factors  of  first  importance. 
The  propriety  of  their  remo\'al  as  a  corrective  measure  is  obvious. 
A  discussion  of  the  question  of  etiological  precedence  may  be  omitted, 
since  all  treatment  must  resolve  itself  into  procuring  increased  space 
for  the  purpose  of  more  complete  physiological  action  in  respiration 
and  also  room  for  de^•elopment  in  the  dental  region. 

Treatment  of  Contracted  Nares,  Deviated  Nasal  Septa,  and  Other 
Intranasal  Deformities  by  Direct  Separation  of  the  Superior  Maxillae 
through  the  Median  Suture. — As  the  author  has  shown  in  previous 
\^Titings  upon  this  subject,  the  appliance  he  uses  for  separating  the 
maxillae  is  merely  an  adaptation  of  well-known  orthodontic  instru- 
ments and  principles.  The  space  that  appears  between  the  central 
incisors,  which  is  indicative  of  division  through  the  median  maxillary 
suture,  has  been  frequently  noticed  by  many  dentists  and  orthodontists, 
who  have  had  it  occur  accidentiilly  in  the  course  of  their  treatment. 

His  only  claim  of  originality  lies,  therefore,  in  the  application  of 
these  principles  for  the  specific  purpose  of  producing  maxillary  separa- 
tion in  order  that  widening  of  the  nares  and  correction  of  nasal  defects 
might  be  the  direct  result.  The  surgical  operation  for  the  immediate 
accomplishment  of  maxillary  separation  as  described  and  illustrated 
in  this  chapter  is  believed  to  be  new  and  original  with  the  author. 
It  is  undoubtedly  true  that,  having  thus  obtained  the  increased  size 
in  the  dental  arch  through  expansion,  the  proper  space  allowed  enables 
Nature  to  correct  many  dental  irregularities  in  considerable  measure 
without  further  interference.  Unless  locked  in  lingual,  labial,  or  buccal 
occlusion,  or  for  some  other  reason  held  in  malposition  by  forces  or 
factors  which  cannot  thus  be  o^'ercome,  the  natural  tendency  of  all 
teeth  is  to  seek  their  rightful  positions  in  the  dental  arch  and  to  assmne 
proper  occlusal  relations. 

The  author  has  previously  estimated  that  about  75  per  cent,  of  the 
orthodontia  now  considered  necessary  would  not  be  required  were 


TREATMENT  OF  CONTRACTED  NARES  55l 

this  simple  procedure  performed  at  a  sufficiently  early  date.  Others 
have  made  somewhat  higher  estimates.  Notwithstanding,  he  wishes 
it  to  be  clearly  understood  that  this  method  is  in  nowise  brought 
forward  as  a  complete  substitute  for  well-known  orthodontic  systems. 
It  is  often  necessary  to  employ  the  principles  and  methods  of  ortho- 
dontia to  complete  what  has  been  accomplished  by  maxillary  separation 
and  to  secure  permanence  for  the  improved  condition  by  correct 
occlusion  of  the  teeth  in  both  jaws. 

The  kind  of  pressure  exerted  in  the  ordinary  course  of  tooth  regu- 
lation by  orthodontists  and  dentists  will  not  give  the  increased  intra- 
nasal space  or  make  possible  the  correction  of  nasal  defects,  in  any- 
thing like  the  same  degree,  even  in  young  children,  and  in  adult  cases 
it  is  extremely  doubtful  if  any  improvement  of  sufficient  value  to 
improve  marked  deflection  of  the  septum  could  be  secured  in  any  other 
way  than  by  direct  pressure  which  will  cause  separation  of  the  maxillary 
bones. 

The  reasons  for  this  statement  are  exceedingly  sunple.  The  prin- 
ciples of  the  various  orthodontic  systems  now  in  vogue  require  pres- 
sure which  will  cause  a  gradual  movement  of  the  teeth.  The  result 
of  pressure  so  exerted  is  to  cause  bone  absorption.  This  Talbot  has 
amply  proved. 

There  are  many  reasons  why  slow  movement  of  teeth  is  advantageous 
when  applied  to  the  correction  of  dental  irregularities. 

In  order  to  carry  the  effect  to  the  higher  region  of  the  nose,  the  less 
movement  of  the  teeth  through  the  alveolar  structures  takes  place 
the  better  the  result  will  be,  insofar  as  widening  of  the  nares  is  con- 
cerned. 

For  this  reason  more  or  less  disappointment  has  sometimes  occurred 
when  rhinologists  have  referred  these  cases  to  orthodontists  and  den- 
tists. Although  the  teeth  may  have  become  beautifully  straightened 
and  symmetrical  arches  secured,  the  nasal  improvement  was  not  such 
as  it  might  have  been  had  the  process  of  direct  pressure  here  recom- 
mended been  applied  and  a  positive  result  obtained  within  a  period  of 
approximately  two  weeks. 

Practical  illustrations  of  the  truth  of  this  statement  are  almost 
unlimited,  and  could  be  multiplied  by  descriptions  of  almost  innu- 
merable cases  in  practice  during  the  last  few^  years.  The  pathological 
explanation  seems  to  be  established  with  equal  certainty  when  Talbot's 
experiments  on  dogs  are  considered  and  the  author's  own  results  of 
expansion  upon  green  skulls.     Both  are  here  given. 

Talbot's  experiments  with  regulating  appliances  in  the  mouths 
of  dogs  were  as  follows:  The  screws,  which  were  given  one-fourth, 
one-half,  and  one  full  turn  every  evening,  were  60  threads  to  the  inch. 
The  teeth  of  the  three  dogs  were  moved  -2^0^,  xt7»  ^^^  ~io  of  an  inch 
daily,  respectively.  The  process  in  which  the  screw  was  turned  one- 
fourth  and  one-half  turn  each  day  was  continued  for  seven  days;  the 
one  in  which  the  screw  was  turned  one  full  turn  was  continued  for 


552        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLJi: 

two  weeks.  The  object  was  to  set  up  pathological  changes  in  the 
alveolar  process  similar  to  those  produced  in  the  human  mouths. 
Talbot's  findings,  proved  by  microscopic  section  of  jaws  of  the  dogs 
thus  treated,  show  beyond  question  that  movement  under  these  con- 
ditions is  effected  by  the  ordinary  processes  of  bone  absorption.^ 

The  surgical  division  to  which  the  author's  practice  is  limited, 
and  the  constant  observation  of  the  marked  nasal  and  maxillary 
deformities  which  occur  in  harelip  and  cleft  palate  cases,  have  impressed 
upon  his  mind  the  fact  that  there  are  some  principles  having  a  direct 
bearing  upon  this  subject.  Its  rationale  in  nasomaxillary  develop- 
mental relation  can  be  more  accurately  observed  in  those  cases  than 
in  the  course  of  normal  growth,  because  through  the  opening  in  the 
palate  and  in  the  lip  the  form  of  the  nasal  septa  affected  by  normal 
conditions  can  be  directly  studied  with  the  entire  field  in  view.  The 
resulting  changes  in  form  and  structure  of  both  osseous  and  cartilagi- 
nous nasal  structures  by  adverse  muscular  action  can  also  be  plainly  seen. 

Although  conditions  may  in  many  respects  be  radically  different 
when  there  are  no  fissures  through  the  palate  or  lip,  the  factors  which 
play  a  part  in  determining  both  intra-  and  extranasal  form  results, 
though  modified  in  degree,  are  in  effect  precisely  the  same.  The 
reader  is  therefore  referred  to  the  illustrations  of  these  cases  and  the 
descriptions  which  accompany  them  for  confirmation  of  the  principles 
which  underlie  this  method  of  correcting  lesser  nasal  defects. 

The  author  believes  the  defects  to  be  accounted  for  by  the  double 
development  of  the  nasal  septum  which  occurs  more  often  than  is 
commonly  realized.  Not  only  is  the  effect  noticeable  in  bulging  or 
buckling  on  opposite  sides  of  the  same  septmn,  but  the  author  has 
recently  had  under  his  care  an  infant,  born  with  double  harelip  and 
cleft  palate,  in  which  there  was  a  continuous  line  of  attachment  from 
the  nasal  septum  to  the  maxillary  division  of  the  palate  upon  each  side, 
the  entire  central  portion  being  open  and  apparently  not  connected 
with  the  nares.  This  condition  was  discovered  in  an  effort  to  pass 
a  catheter  through  the  nose  for  the  purpose  of  continuing  anesthesia 
during  the  operation  for  closure  of  the  palate.  The  catheter,  when 
inserted  and  passed  through  the  nose,  appeared  quite  close  to  the 
Eustachian  opening,  and  could  not  be  passed  directly  through  into 
the  wide  open  space  in  the  center  of  the  palate  (Fig.  340) . 

The  best  description  of  the  double  development  of  the  anatomical 
parts  of  the  nasal  septum,  the  nasal  processes,  the  vomer,  the  vertical 
plate  of  the  ethmoid,  the  upper  maxillary,  the  triangular  cartilage 
and  its  caudal  prolongation,  and  the  relation  of  the  premaxillary  wings, 
as  affected  by  developing  tooth  germs,  reflecting  upon  the  form  of  the 
septum,  has  been  given  with  supporting  evidence  from  the  anatomical 
room  in  an  exceedingly  complete  series  of  illustrations  by  Harris 
Peyton  Mosher,  of  Boston,  who  states : 

•  Talbot:  Interstitial  Gingivitis. 


TREATMEXT  OF  CONTRACTED  NARES 


553 


"The  septum  at  birth  is  ahnost  cartilage.  The  only  bony  parts 
are  the  vomer  and  the  two  premaxillse  and  their  processes.  The  \omer 
consists  of  two  leaves  of  thin  bone,  which  are  united  below,  but  are 
open  and  flaring  above.  This  formation  is  a  relic  of  its  double  origin, 
evidences  of  which  the  vomer  never  entirely  loses.  The  premaxillary 
wings  spring  from  the  posterior  half  of  the  upper  face  of  the  premaxillse. 
In  the  groove  in  which  they  form  rests  the  tip  of  the  vomer.  Two 
other  processes  spring  from  the  superior  surface  of  the  premaxillse, 
namely,  the  nasal  spines.  These  again  make  a  slight  gutter,  into 
which  in  its  turn  fits  the  tip  of  the  premaxillary  wings.  The  tip  of  the 
vomer  rests  in  the  gutter  of  the  premaxillary  wings,  and  the  tip  of 
the  premaxillary  wing  rests  in  the  gutter  of  the  nasal  spines,  like  the 
arrangements  of  the  sections  of  the  old-fashioned  wooden  drain.  The 
upper  border  of  the  adult  vomer  is  gutter-shaped,  like  the  vomer  at 
birth,  the  gutter  not  being  so  deep. 


Fig.  340. — Double  development  of  the  nasal  septum,  -with  central  groove  through  nose 
and  median  fissure  of  the  upper  lip  and  palate. 


"A  large  number  of  deviations  of  the  septum  are  caused  by  asjmi- 
metry  in  the  de\-elopment  of  the  bones  which  make  the  hard  palate. 
This  inequality  of  the  development  is  usually  due  to  delayed  or  irregu- 
lar eruption  of  the  incbor  teeth,  especially  of  the  middle  incisor.  "\Mien 
the  eruption  of  one  central  mcisor  is  sufficiently  belated  it  causes  a 
deformity  or  h^-pertrophy  of  the  maxillary  wing  above  it.  This  distorts 
the  retaining  groove  made  by  the  premaxillary'  wings.  As  a  result  the 
septmii  slips  from  its  bed  in  the  vomer,  and  the  grooves  made  by  the 
two  leaves  of  the  vomer  spread  open,  one  leaf  on  the  side  of  the  vomer 
disappearing.  This  produces  a  spur  along  the  upper  edge  of  the  vomer. 
As  the  cartilaginous  part  of  the  septum  slips  from  its  bed  the  lower  edge 
curls  upward  and  outward,  so  that  its  lowest  portion  becomes  concave. 
Higher  up  on  the  septum  this  concavity  gives  place  to  a  compensatory 
convexity.  The  convexitj^  generally  is  toward  the  spur.  On  the  side 
of  the  delayed  tooth  a  short  basal  spur  indicates  the  enlarged  pre- 
maxillary wing.  The  upper  wisdom  tooth  may  deform  the  septum 
posteriorly.     This  as^imnetry  shows  in  the  nasal  notches  anteriorly 


554        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLM 

and  in  the  choanse  posteriorly  and  in  the  mouth.  Abundant  dissecting- 
room  findings  prove  that  de\'iations  so  started  may  extend  far  back- 
ward on  the  septum  and  become  obstructive." 

It  is  interesting  that  this  evidently  painstaking  and  exhaustive  study 
of  embr}'onic  and  later  anatomical  study,  supported  by  evidence  from 
the  dissecting  room,  coincides  so  perfectly  with  the  results  of  our  study 
of  maldevelopment  and  clinical  experience  in  this  region.  With 
Mosher's  illustrations  and  descriptions  before  one,  there  can  be  no 
doubt  of  the  practical  corrective  efficiency  of  a  method  which  would 
separate  the  halves  of  these  developing  parts  sufficiently  to  supply 
space  for  their  assumption  of  their  normal  form,  which  had  been  denied 
them  through  insufficient  room  for  proj^er  de\elopment.  The  elabora- 
tion of  the  gutter  form  of  the  premaxillary  wings  and  vomer,  and  other 
evidence  submitted  shows  that  with  deviations  of  the  septum  the  first 
tendency  is  to  slip  out  of  the  trough  which  forms  its  natural  resting 
place.  This  makes  it  plain  the  reason  why  straightening  of  the  septum, 
even  in  adult  patients,  takes  place  in  such  marked  degree  when  the  max- 
illary bones  are  separated.  This  has  been  proved  over  and  over  again 
in  our  clinical  experience,  but  there  has  been  some  hesitancy  about 
claiming  it  to  the  extent  which  results  seemed  to  warrant,  but  now  the 
assumption  may  be  that  the  separation  must  necessarily  reestablish 
the  gutter  form  and  allow  the  naturally  resilient  septum  to  seek  its 
proper  resting  place. 

Obviously,  the  simple  and  most  natural  method  of  correction  must 
lie,  insofar  as  possible,  in  the  application  of  force,  which  will  directly 
overcome  not  only  the  first  causes,  but  the  secondary  results  as  well. 

The  author's  appliance,  as  showTi  in  Fig.  341,  is  constructed  by 
adjusting  metal  bands  to  fit  the  cuspids  and  the  first  or  second  molar 
teeth  upon  each  side  of  the  mouth.  These  are  connected  by  rigid 
metal  bars  which  rest  against  the  lingual  sides  of  all  intervening  teeth. 
To  the  side  bar  upon  one  side  a  metal  tube  is  attached  into  which  fits 
a  threaded  wire  extending  from  the  opposite  side  with  a  nut  adjusted  to 
fit.  These  are  so  arranged  as  to  make  direct  pressure  across  the  palate 
at  the  point  of  greatest  constriction  when  the  nut  is  turned.  Force  as 
thus  applied  is  distributed  against  all  of  the  teeth  upon  each  side  of 
the  dental  arch,  and  by  turning  the  nut  twice  daily,  continuing  each 
time  until  firm  pressure  is  felt  but  no  pain  whate\er  experienced,  the 
maxillse  can  be  separated  through  the  median  suture  of  the  palate 
and  division  between  the  central  teeth.  When  this  occurs,  the  incisor 
teeth  are  moved  apart,  and  since  the  appliance  does  not  touch  them 
in  any  way,  the  only  explanation  is  that  the  bones  in  which  their  roots 
have  been  embedded  have  been  moved  away  from  each  other.  Both 
intra-  and  extranasal  measurements  prove  that  in  this  movement  the 
nasal  bones  and  other  attached  parts  have  also  been  included,  with  the 
result  that  there  is  a  direct  and  immediate  increase  of  space  within  the 
nares.  To  prove  this  definitely,  similar  appliances  were  adjusted  to 
green  skulls.     The  result  is  showTi  in  Figs.  341  and  342,  in  which  the 


TREATMEXT  OF  CONTRACTED  XARES 


555 


Fig.  341. — Expansion  appliance  as  used  by  the  author  in    separating  the  maxillse  to 

widen  the  nares. 


Fig.   342. — Front  view  of  skull  shown  in  Fig.  341.    Division  between  the  maxillarj-  bones 
up  to  the  nose  may  be  noted. 


556       NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 

parted  sutures  can  be  plainly  noted,  with  increase  in  actual  measure- 
ment of  one-eighth  of  an  inch  across  the  base  of  the  nose  and  one- 
sixteenth  of  an  inch  across  the  upper  third. 

When  the  upper  dental  arch  has  been  expanded  it  is  obviously 
necessary  to  enlarge  the  lower  jaw  to  correspond  in  order  to  secure 
correct  occlusion  of  the  teeth.  This  can  be  done  without  unusual 
difficulty  by  orthodontic  methods. 


Fig.  343. — Shows  splint  in  place  with  expansion  screw  bar  across  the  palate.  Vertical 
incision  as  made  above  and  between  the  roots  of  the  central  incised  teeth  down  to  the 
bone  at  the  intermaxillary  suture. 


The  Immediate  Surgical  Separation  of  the  Superior  Maxillary 
Bones  to  Widen  the  Nares  for  the  Improvement  of  Respiratory  and 
Other  Conditions  According  to  the  Author's  Operation. — The  day 
before  the  operation  is  performed  an  expansion  splint  is  cemented 
to  the  teeth.  This  appliance  is  in  all  respects  the  same  as  previously 
described  for  the  slower  method  of  rapid  maxillary  separation,  except 
that  additional  bands  are  cemented  on  both  second  bicuspid  teeth 
with  hooks  to  slide  over  the  side  bars  to  give  greater  firmness. 

The  upper  lip  is  raised  and  a  vertical  incision  about  three-eighths 
inch  long  in  the  median  line  above  and  between  the  roots  of  the  central 
incisor  teeth  is  carried  down  to  the  bone  close  to  the  frenmn  labialis 
super ioris.  The  periosteum  is  then  slightly  raised  on  each  side  of  the 
incision  and  the  tissues  retracted  to  expose  the  intermaxillary  suture. 

A  fine  chisel  is  inserted  into  the  suture  at  this  point,  followed  with 
a  largft-,  more  wedge-shaped  chisel.  A  few  blows  with  a  mallet  forces 
the  chisel  between  the  bones  and  by  tightening  the  screw  the  separation 
is  made  complete  (see  Fig.  345) . 


SEPARATION  OF  SUPERIOR  MAXILLARY  BONES 


557 


Fig.    344. — Chisel  at  the  intermaxillary  suture  being  driven  between  the  bones  by  gentle 

blows  with  a  mallet. 


Fig.  345. — Turning  the  nut  on  the  cross  bar  of  the  appliance  after  the  maxillary  bones 
have  been  partially  set  free  by  separation  through  their  intermaxillary  and  median 
palatine  sutures.  The  space  between  the  central  incisor  teeth  which  are  not  touched 
by  the  appliance  indicates  the  complete  accomplishment  of  the  separation  of  the  maxillae. 
By  turning  the  nut  during  the  first  few  days  after  the  operation  as  much  enlargement  as 
necessary  may  be  secured.  It  is  therefore  both  undesirable  and  unnecessary  to  apply 
much  force  with  the  expansion  screw  during  the  operation  while  the  patient  is  uncon- 
scious.   In  this  way  any  possible  danger  of  injury  to  the  teeth  is  avoided. 


558        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLyE 

In  this  way  the  maxillae  are  forced  apart,  carrying  with  them  the 
attached  nasal  bones.  The  result  is  a  direct  increase  in  size  of  the 
nares. 

The  almost  instantaneous  effect  of  forcing  the  maxillpe  apart  after 
surgical  separation  appears  to  exert  a  more  pronounced  influence  in 
the  graver  types  of  cases  than  the  slower  method  of  depending  upon 
pressure  against  the  teeth  alone  as  in  non-surgical  rapid  expansion 
of  the  upper  dental  arch. 

The  freer  bone  movement  thus  allowed  gives  less  tendency  to 
flanging  of  the  teeth,  and  the  relation  of  intranasal  enlargement  to  the 
increased  width  across  is  proportionately  improved. 


Fig.  346. — Young  man,  aged  twenty-nine  years,  with  nose  injured  in  early  youth.    Badly 
buckled  septum  and  almost  complete  stenosis  of  one  naris. 


Clinical  Results. — The  follo\A-ing  cases  are  fair  examples  of  the  usual 
clinical  results.  P'ig.  346  shows  a  young  man,  aged  twenty-nine  years, 
whose  nose  was  injured  by  a  baseball  in  early  youth.  Dr.  Nelson  M. 
Black,  by  whom  the  patient  was  referred  to  the  author,  found  the 
septum  buckled  in  such  a  way  as  to  give  almost  complete  stenosis  of 
one  naris,  the  turbinal  bodies  much  enlarged,  and  hypertrophic  con- 
ditions generally  marked.  The  patient  was  greatly  troubled  by  attacks 
of  sneezing  when  he  bent  his  head  downward.  The  appliance  was 
adjusted  April  6,  1908.  "Within  two  weeks  the  space  between  the  cen- 
tral incisors  appeared  as  shown  in  Fig.  347.  Actual  enlargement  of 
the  nares  was  confirmed  on  examination  by  Dr.  Black,  and  by  the  im- 
proved breathing  experienced  on  the  part  of  the  patient  himself,  thus 
proving  that  even  at  this  patient's  age  the  desired  result  had  been 
quickly  accomplished.  ]Most  of  the  tune  the  patient,  who  resides  in 
another  city,  was  at  a  distance  from  the  author,  and  had  the  appliance 
turned  by  one  of  the  members  of  his  family. 


SEPARATION  OF  SUPERIOR  MAXILLARY  BONES 


559 


Fig.  348  gives  the  central  measurement  with  a  milHmeter  gauge 
of  two  casts  of  the  mouth  of  a  lad,  aged  fourteen  years,  one  taken 


Fig.  347. — Same  young  man,  about  ten  days  later.  Separation  between  the  ventral 
incisors  confirmed  by  intranasal  examination,  which  disclosed  enlargement  in  this  region, 
evidence  maxillary  separation. 


Fig.  348. — Casts  of  the  mouth  of  a  boy,  aged  fourteen  years,  before  and  after  expan- 
sion. The  space  between  the  central  incisors  closes  itself  in  the  course  of  time  without 
operative  influences. 


.^aawf 

^wwEh 

i  •  >. 

^^^^^H 
^^^^^■i 

Bp^^T^ 

NH 

^HL 

,^j^H 

i^^l 

¥  !i 

1 

Fig.  349.— Skiagrams  of  the  mouth  of  a  girl,  aged  eight  years,  a.  Showing  appliance 
in  place  but  before  pressure  has  been  applied — taken  June  29,  1913.  b,  the  same  mouth 
July  29,  1913.  This  result  might  have  been  secured  much  earlier  except  for  delays  which 
occurred  by  the  patient  being  out  of  the  city. 


560        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 


Fig.  350. — This  girl  had  for  years  been  a  great  sufferer  from  bronchial  asthma.  Her 
father  at  forty  years  of  age  is  still  a  great  sufferer  from  the  same  affection.  She  has  been 
almost  entirely  free  from  severe  attacks  for  a  long  period  and  although  having  more  or 
less  mild  asthmatic  disturbahce,  was  able  to  attendschool  regularly  all  last  winter.  This 
was  impossible  before  her  upper  dental  arch  was  expanded  and  nose  enlarged.  There  is 
also  much  improvement  in  the  form  of  her  chest  and  back.  It  is  confidently  believed 
that  she  will  now  entirely  outgrow  all  of  these  defects. 


Fig.  351. — Girl  formerly  affected  by  asthma  who  has  been  entirely  free  from  attacks 
since  upper  maxillary  expansion  was  performed,  which  warrants  the  st.Tt.ement  that  she 
is  entirely  cured.  Formerly  she  could  not  ride  behind  horses  without  having  severe 
asthmatic  trouble. 


SEPARATION  OF  SUPERIOR  MAXILLARY  BONES 


561 


Fig.  352. — Tubercular  girl  with  marked  scoliosis  who  is  now  in  good  health.  Repeated 
von  Pirquet  tests  negative,  although  her  back  will  undoubtedly  require  additional  cor- 
rective treatment. 


Fig.  353. — The  same  girl  shown  in  Fig.  352.     The  shape  of  the  face,  nose,  and  chest 
indicate  the  necessity  of  this  treatment. 


36 


5G2        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 

before  the  arch  was  separated,  the  other  at  the  time  when  the  division 
through  the  central  incisors  was  evident,  and  his  rhinologist  reported 
sufficient  improvjpment  of  his  nasal  condition.     This  is  a  fair  example 


Fig.  354 


Fig.  355 


Fig.  354. — Skiagram  of  the  mouth  of  a  boy,  aged  twelve  years,  who  was  a  chronic 
sufferer  from  hay  fever,  headaches,  bronchitis,  and  general  nervous  conditions,  particu- 
larly noticeable  in  winking  of  the  eyelids.  Marked  improvement  in  all  these  symptoms 
followed  widening  of  his  upper  dental  arch  in  July,  1912.  The  skiagram  of  his  palate 
was  taken  January  11,  1913.  The  thick  black  line  along  the  line  of  the  median  palatine 
suture  seems  to  indicate  new  bone  formation  in  that  region.  During  these  six  months 
his  growth  in  height  was  increased  two  and  three-quarter  inches. 

Fig.  355. — Skiagram  of  the  palate  of  a  young  man,  aged  twenty-eight  years,  for 
whom  wide  separation  of  the  median  palatine  suture  was  performed,  with  great  benefit 
to  nasal  and  general  pathological  conditions;  taken  two  years  afterward.  The  thick  dark 
line  shown  where  new  bone  had  formed  in  the  line  of  the  formerly  separated  luedian 
palatine  suture  proves  that  the  osteogenetic  layer  of  the  palatal  periosteum  does  become 
active  under  these  conditions  and  that  new  bone  formation  results. 


Fig.  356. — The  result  of  traumatic  injury. 
(Wurdeman  and  Black.) 


Fig.  o.'iT. — '  MiToction  made  possible 
by  widening  the  nares  as  a  preparatory 
measure.     (Wurdeman  and  Black.) 


of  the  approximate  increase  in  width  of  the  palate  that  is  required  in 
such  cases.  Figs.  356  and  357  show  what  may  be  done  by  maxillary 
expansion  to  prepare  for  surgical  correction  of  nasal  deformity  in  other 
respects. 


SEPARATION  OF  SUPERIOR  MAXILLARY  BONES  563 

To  these,  if  repetition  by  citation  of  other  cases  were  either  necessary 
or  advisable,  a  long  list  of  other  patients  who  have  received  the  same 
treatment  with  precisely  the  same  result  in  the  author's  practice  during 
the  last  few  years  might  be  added.  All  show  deviation  of  the  nose 
from  the  central  facial  line,  an  imaginary  though  clinically  a  very  useful 
line,  taken  through  center  of  forehead,  tip  of  nose,  and  center  of  chin. 
Deviation  from  this  line,  one  way  or  another,  is  a  fairly  certain  indi- 
cation of  perverted  nasal  and  maxillary  gro^^i:h,  leading  almost  invari- 
ably to  pathological  conditions. 

Especially  among  growing  children  treated  by  this  method  has 
there  been  marked  physical  improvement,  tendency  to  growth  in 
height,  as  well  as  general  development  and  increase  in  weight.  ]\Iany 
had  previously  been  unable  to  attend  school  regularly  because  of  the 
tendency  to  nose,  throat,  and  bronchial  affections.  Nervousness  was 
almost  invariably  very  greatly  relieved,  and  this,  it  is  believed,  for  two 
reasons:  (1)  The  well-understood  results  from  the  improvement  in 
breathing  apparatus,  with  general  healthfulness  to  be  expected  from 
better  aeration  and  freedom  from  diseased  nasal  secretions;  (2)  the 
relief  from  the  crowding  together  of  the  dental  arches,  with  tendency 
to  nerve  irritation.  This  condition  quite  frequently  manifests  itself, 
not  only  in  increased  nervousness  of  a  general  character,  but  also  in 
the  development  of  neiu-otic  tendencies  leading  to  chorea,  epilepsy,  and 
other  similar  affections.  In  some  instances,  at  least,  these  disorders 
might  perhaps  have  been  averted  if  the  patients  could  have  been  tided 
over  critical  periods  in  their  development.  It  is  a  curious  fact  that 
even  with  the  disadvantage  of  having  the  appliance  in  their  mouths 
and  the  bar  across  the  palate,  children  who  are  subject  to  such  patho- 
logical states  almost  immediately  become  less  nervous,  have  increased 
appetites,  and  general  development  goes  forward  almost  from  the  very 
first  few  days  after  pressure  has  begun  to  be  exerted. 

This  treatment  might  be  made  a  very  great  factor  in  safeguarding 
against  tuberculosis.  It  is  so  easily  accomplished  and  the  results  are 
so  greatly  beneficial  that  it  should  be  applied  to  hundreds  of  thousands 
of  growing  children,  who  are  unquestionably  more  susceptible  to 
pneumonia  and  bronchial  affections  because  of  imperfect  breathing. 
It  offers  a  possibility  of  relief  which  is  especially  miportant  because 
such  defects  are  well  kno^Ti  to  be  on  the  increase,  arrested  develop- 
ment in  the  maxillary  region  being  more  marked  in  each  generation 
under  the  conditions  of  our  so-called  civilization. 

In  the  final  proof  of  the  foregoing  theoretical  and  clinical  conclusions, 
the  author  is  privileged,  through  the  coiu-tesy  of  Dr.  Lee  W'.  Dean, 
of  the  State  University  of  Iowa,  to  submit  to  the  follo\nng  record  of  a 
young  girl,  aged  seventeen  years,  a  patient  of  Dr.  Dean,  for  whom 
maxillary  separation  was  performed  to  aid  the  correction  of  serious 
nasal  and  other  defects.  These  measurements  were  made  with  an 
instrument  invented  by  Dr.  Dean  for  the  purpose,  and  taken  by  his 
associate,  who  had  no  special  interest  in  the  case,  and  whose  accuracy 


564       NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 

could  in  nowise  be  consciously  or  unconsciously  affected  by  any  pre- 
conceived idea  or  expectation.    They  are  therefore  absolutely  correct. 


Anterior  end  of  inferior  turbinate  to  septum 
Middle  of  inferior  turbinate  to  septum 
Posterior  end  of  inferior  turbinate  to  septum 
Anterior  end  of  middle  turbinate  to  septum  . 
Middle  of  middle  turbinate  to  septum 


A 

May 

28,  1909 

R.          L. 

B 

August 

11,  1909 

R.          L. 

C 

February 

18,  1910 

R.          L. 

.        5            6 

8 

9 

9         10 

5           4 

7 

6 

7           6 

.      10          12 

10 

12 

12         12 

2           2 

2 

2 

4 

1            2 

2 

2 

2           1 

Fig.  358. — Back  and  shoulder  -vdew  of  a  girl,  aged  fifteen  years,  with  marked  spasm 
of  the  right  side  of  the  face,  right  arm  and  right  leg.  Explosive  and  slurring  speech. 
Almost  total  relief  froni  these  symptoms  was  secured  in  less  than  thirty  days  after  pres- 
sure was  applied  to  spread  the  upper  maxilloe  apart  to  enlarge  the  nose.  Three  months 
later  she  was  so  improved  that  she  was  able  to  crochet  a  pair  of  silk  slippers  with  a  needle 
held  in  her  right  hand  which  was  formerly  quite  helpless.  (Author's  article,  Ochsner's 
Surgery,  vol.  i.) 

Having  thus  fully  demonstrated  the  practicability  of  the  unprove- 
ment  of  nasal  deformities  and  attendant  disease  by  separating  the 
maxillary  bones  and  directly  increasing  the  size  of  the  nares,  it  only 
remains  to  prove  that  constriction  or  arrest  of  growth  in  width  across 
the  palate  could  cause  deviated  septum,  contracted  nares,  or  even 
complete  stenosis. 

This  the  author  has  been  able  to  do.^     Several  pups  eight  weeks 

'  Through  the  courtesy  of  the  Parke,  Davis  &  Co.  Laboratory,  in  whose  Biological 
and  Research  Department  he  was  permitted  to  do  original  work  on  puppies,  with  the 
able  assistance  of  Dr.  Ferry  and  his  associates  in  the  laboratory. 


SEPARATION  OF  SUPERIOR  MAXILLARY  BONES 


565 


Fig.  359. — Same  patient  shown  in  Fig.  358.     The  shape  of  face  and  nose  gives 
indication  of  her  great  need  of  nasal  widening. 


little 


Fig.  360  Fig.  361 

Fig.  360. — Boy,  aged  eleven  years.  Diagnosis:  Little's  disease.  At  the  time  his 
jaw  was  erpanded  he  was  unable  to  walk  without  assistance  and  had  practically  no 
control  of  his  tongue,  so  that  it  was  almost  impossible  to  understand  his  attempts  at 
speech  satisfactorily,  a  drooling  from  his  mouth  constantly,  and  other  typical  symptoms 
of  this  affection.  He  is  now  able  to  walk  about  without  assistance  and  speaks  sufHciently 
well  to  be  understood,  can  grasp  a  pencil  in  one  hand  and  write  his  name  (Sam).  No 
other  treatment  has  been  given  since  his  maxillary  expansion  was  performed. 
Fig.  361. — Back  view  of  same  boy  shown  in  Fig.  360. 


566        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 

old  were  operated  upon  by  passing  a  wire  through  the  maxillae  from 
a  point  above  the  roots  of  the  teeth  upon  one  side  above  the  palate 
and  out  at  a  corresponding  point  upon  the  opposite  side.     The  palate 


SEPARATION  OF  SUPERIOR  MAXILLARY  BONES  567 

was  compressed  sufficiently  to  force  the  upper  teeth  inside  or  in  lingual 
occlusion  with  the  lowers,  so  that  the  upper  and  lower  jaws  of  these 
puppies  were  placed  in  about  the  same  occlusal  relation  that  exists 
in  growing  children  whose  bicuspid  teeth  meet  the  corresponding  lower 
teeth  in  lingual  (inside)  instead  of  buccal  (outside)  or  normal  occlusion. 
Not  nearly  so  much  force  in  compression  was  used  as  would  be  necessary 
to  close  a  case  of  palate  fissure  according  to  the  method  which  was 
formerly  widely  practised  upon  infants  with  cleft  palate.  The  pur- 
pose was  to  reproduce  as  nearly  as  possible  the  maxillary  condition  of 
typical  cases  of  mouth-breathing  children.  One  pup  was  kept  without 
operation  as  a  control,  and  all  were  allowed  to  develop  until  they 
reached  the  age  of  six  months,  which,  it  was  estimated,  would  approxi- 
mately correspond  to  the  age  of  a  child,  aged  eight  or  nine  years.  The 
puppies  were  then  killed,  the  heads  frozen,  and  sections  cut  through 
the  nose  and  upper  jaws  at  short  intervals.  The  result  is  showni  in 
Figs.  362  and  363.  :Marked  difference  between  the  nares  will  be  noted 
in  both  series,  but  the  section  marked  C  in  each  is  exactly  at  the  point 
where  compression  was  made.  The  almost  complete  stenosis  in  Fig. 
363  contrasts  strongly  with  the  same  section  in  Fig.  362. 

The  laboratory  record  shows  that  all  of  the  puppies  in  this  litter, 
under  the  same  car© and  \\'ith  the  same  food,  for  a  time  thrived  equally 
well,  and  their  growth  was  about  the  same.  During  the  latter  portion 
of  the  period,  when  the  effect  of  the  compression  upon  nasal  growth 
became  apparent,  the  control  dog  continued  to  grow  and  thrive,  but 
those  operated  upon  became  emaciated.  One  died  shortly  before  the 
expiration  of  the  trial  period.  The  one  shown  in  the  illustration  was 
a  mere  mass  of  skin  and  bone.  The  remaining  puppy  showed  marked 
congestion  of  the  lungs.  The  late  Dr.  Willis  S.  Anderson,  of  Detroit, 
by  experiments  conducted  in  the  Parke,  Davis  &  Co.  Laboratory, 
produced  partial  stenosis  in  dogs  by  sutiu-ing  the  external  nasal  open- 
ings and  by  introduction  of  packings  in  several  ways.  He  demon- 
strated that  the  mucous  membrane  of  the  bronchi  of  dogs  in  good  health 
is  practically  immune  to  pathogenic  micro5rganisms;  when  breathing 
is  affected,  however,  it  becomes  susceptible  to  every  sort  of  infection. 
Such  dogs  become  ahuost  entirely  hairless,  and  the  puppies  of  such 
mothers  in  some  instances  lost  their  hair  also. 

As  is  well  known,  children  who  are  mouth-breathers  because  of 
adenoids,  enlarged  tonsils,  or  arrested  or  perverted  nasal  development, 
are  frequent  sufferers  from  coughs,  colds,  and  other  evidences  of 
infectious  processes  in  this  region.  The  same  is  true  with  older  persons 
in  corresponding  degree. 

Having  thus  been  able  to  cause  deviated  nasal  septum  and  con- 
tracted nares  by  arresting  maxillary  development,  and  to  correct  these 
deformities  and  their  attendant  ills  by  maxillary  separation  it  seems 
fair  to  assume  that  our  case  is  complete. 

With  the  development  of  knowledge  pertaining  to  the  vegetative 
nervous  system  and  the  far-reaching  effect  upon  physiological  and 


568 


NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 


pathological  phenomena  that  are  controlled  by  the  counteracting 
adjustment  of  the  balance  between  the  sympathetic  and  vagus  systems, 
much  that  has  hitherto  been  etiologically  and  pathologically  obscure 
is  rapidly  coming  to  be  better  understood,  and  this  is  particularly  true 
of  treatment  by  jaw  expansion. 

It  is  well  known  that  "The  vagus  system  supplies  the  large  glands 
of  the  abdominal  cavity,  the  lower  two-thirds  of  the  esophagus,  the 
stomach,  and  the  intestines  as  far  as  the  descending  colon.  The 
s>Tnpathetic  supplies  the  tract  from  one  end  to  the  other. 

"The  ganglion  cells  of  the  w^alls  of  the  intestines  control  this  move- 
ment of  the  intestinal  organs,  but  the  sjinpathetic  and  \agus  exercise 
the  regulatory  functions  of  acceleration  or  inhibition. 

"The  vagus  nerve  through  its  depressor  nerve  exercises  an  inhib- 
itory action  on  the  heart,  while  the  SAinpathetic  through  its  acceler- 
ation nerves  has  acceleration  functions.  In  the  digestive  tract  this 
is  reversed.    The  vagus  accelerates.    The  sympathetic  inhibits." 


Fig.  364. — A  child,  aged  eleven  jear-,  with  chorea  and  enuresis,  winking  of  the  right 
eye  and  facial  spasm  of  the  right  side  of  the  face  and  nose.  Recently  operated  upon  and 
much  improved.  Illustrates  the  type  of  face  with  high-arched  palate  and  mouth-breath- 
ing for  which  maxillary  separation  is  demanded. 


Higler^  calls  attention  to  the  existence  of  the  following  structures, 
the  enumeration  of  which  is  important  for  an  intelligent  understanding 
of  our  present  subject,  (a)  Ciliary  ganglion  lying  in  the  posterior 
part  of  the  orbit  which  supplies  the  sphincter  iridid  and  the  ciliary 
muscle;  (6)  the  sphenopalatine  ganglia  lying  on  the  pterygopalatine 
fossa  which  supplies  the  lacrimal  gland  and  the  mucous  glands  of  the 
nasopharynx;  (c)  the  otic  ganglia  lying  under  the  foramen  ovale  which 

1  Vegetative  Neurology,  Journal  of  Mental  and  Nervous  Diseases:  by  Heinrick  Higler, 
Warsaw;  translation  by  Walter  Max  Kraus,  New  York. 


SEPARATIOX  OF  SUPERIOR  MAXILLARY  BONES 


569 


supplies  the  parotid  gland;  (d)  the  submaxillary  and  sublingual  ganglia 
whieh  supply  the  corresponding  glands;  (e)  the  automatic  ganglia  (the 


Fig.  365. — Mongolian,  aged  seventeen  years,  approximate  mentality  that  of  seven 
years.  High,  narrow  palate  and  mouth-breathing.  Improvement  since  operation  has 
been  e\-ident  in  this  case,  but  only  time  can  tell  in  any  of  these  cases  how  far-reaching 
the  effect  mav  be. 


Fig.  366. — Back  of  same  girl  shown  in  Fig.  365. 


570        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 

bulbar  part  of  the  vagus  domain)  which  lie  in  organs  and  which  supply 
the  glands  and  muscles  of  the  trachea,  the  heart  muscle,  and  the  gastro- 
intestinal tract  from  the  mouth  to  the  decending  colon.  (/)  The 
ganglion  mesentericum  inferium,  hypogastricum,  and  hemorrhoidale 
which  lie  in  the  upper  and  lower  parts  of  the  pelvis,  supplying  the 
muscles  and  glands  of  the  descending  colon,  the  sigmoid,  the  anus,  the 
genital  apparatus,  and  the  bloodvessels  belonging  thereunto. 


Fig.  367. — Back  of  girl,  aged  fourteen  years.  The  form  of  the  Ijack  with  the  round 
flabby  appearance  due  to  excess  of  lymphatic  tissue  is  characteristic  of  the  Mongolian 
type.  The  distinction  may  be  noted  between  this  and  the  backs  of  the  opposite  types 
of  cases  shown  in  Figs.  352  and  358.  Two  illustrations  of  letters  written  by  this  girl 
give  indication  of  her  progress  after  operation;  what  the  future  may  bring  in  the  way 
of  improvement  no  one  can  tell,  but  her  prospects  are  undoubtedly  better  than  before 
operation. 


With  these  principles  in  view  it  is  no  longer  a  matter  of  wonder 
that  adenoids  and  enlarged  tonsils  or  any  other  pathological  condition 
which  might  tend  to  inhibit  the  great  areaway  of  the  clearing  house 
of  vegetative  nervous  stimulation  in  nose,  pharynx  and  bronchi, 
should  go  hand  in  hand  with  a  typical  cast  of  countenance,  with  ten- 
dency to  colds,  bronchitis  and  asthma;  with  dulness  of  comprehension, 
lack  of  concentration  and  apathy  where  active  bodily  and  mental 
vigor  is  required  and  in  other  cases  the  opposite  condition  of  extreme 
nervousness;  constant  desire  to  overdo  in  the  school,  or  other  mental 
pursuits;  poor  circulation,  irregular  or  very  rapid  heart  action,  insuffi- 
cient chest  development,  spinal  curvatures,  choreic  and  other  muscular 
derangments,  etc. 


SEPARATION  OF  SUPERIOR  MAXILLARY  BONES  571 

It  also  l)ecoincs  plain  that  the  reason  why  tonsillectomy  and  adenoid- 
ectomy,  resections  of  the  nasal  septum,  and  temporarily  at  least  even 
turbinectomy  have  given  such  markedly  beneficial  results  in  so  many  of 
these  cases  is  precisely  because  of  the  efi'ect  of  better  respiration  upon 
the  controlling  balance  of  this  nervous  and  ganglionic  interrelationship. 
In  this  light  also  the  efl'ectiveness  of  a  surgical  measure  which  gives  a 
still  greater  corrective  influence  by  immediate  enlargement  of  both 
nares  and  a  corresponding  increase  of  the  volume  of  air  at  each  respira- 
tion is  readily  understood. 

The  endocrine  organ  activities  are  undoubtedly  important  factors 
in  the  improvement  of  these  cases  as  formerly  believed,  but  it  now 
seems  probable  that  they  are  really  secondary  to  the  stimulation  of 
underlying  nervous  influences  which  control  all  the  ganglionic  and 
glandular  structures.  It  has  been  demonstrated  by  Anderson  and 
also  by  the  author's  experiments  that  interference  with  respiration  by 
occlusion  of  the  nares  from  any  cause  invariably  affects  the  adrenals. 
Relief  in  this  direction  by  improved  respiratory  conditions  combined 
with  better  vagus  control,  easily  accounts  for  the  marked  improvement 
in  the  nervous  muscular  control,  coordination,  spasmodic  affections, 
enuresis,  nervous  speech  defects,  and  other  similar  conditions  that  have 
been  so  uniformly  benefited.  The  application  of  all  these  principles 
and  this  method  as  a  means  of  opening  the  door  toward  constructive 
upward  progress  for  subnormal  and  even  mentally  defective  children, 
presents  a  wide  field  for  investigation  and  study  which  the  author 
believes  gives  great  promise  for  the  future,  when  better  classification 
may  bring  better  recognition  and  selection  of  cases.  Figs.  365  and  367 
illustrate  types  of  children  who  have  been  greatly  benefited  in  this  way. 

The  following  case  illustrates  these  possibilities: 

May  12,  1914.     Aged  eleven  years.     Previous  diagnosis:  idiot. 

History. — Premature  birth.  Slow  development.  Unable  to  sit 
until  between  two  and  three  years  old.  Began  to  talk  when  three 
years  old.  Began  to  walk  about  four  years  old.  Unable  to  sleep  well 
at  any  time.  Mother  often  saw  sunrise  while  trying  to  put  this  child 
to  sleep.  Eyes  were  prominent;  restless  and  foolish  in  expression. 
Coordination  not  bad  except  for  the  erratic  nature  of  all  movements. 
Speech:  strained  nervous  tone  with  defective  sounds  due  to  imperfect 
nervous  muscular  control.  Capable  of  learning  some  things  quickly, 
but  want  of  concentration  and  self-control  made  teaching  almost 
impossible.  Effect  of  maxillary  expansion:  appliance  inserted  May 
18,  1914. 

Report  January  20,  1916. — ^Enuresis  completely  overcome  during 
the  last  two  months.  Appliance  off  about  one  and  one-half  months 
and  no  return  of  old  symptoms. 

Wide  separation  of  incisor  teeth,  with  corresponding  nasal  enlarge- 
ment— the  loud  stertorous  breathing  when  asleep  ceased  as  regular 
nasal  breathing  was  accomplished. 

Among  the  early  noticeable  effects  was  the  changed  appearance 


572        NASAL  DEFORMITIES  AND  DISEASES  OF  MAXILLA 

of  the  eyes.  Mother  without  suggestion  from  anyone  asked,  "Do  I 
imagine  it  or  have  my  daughter's  eyes  changed^"  The  expression 
became  quieter,  the  eyeballs  steadier  and  less  prominent  in  appearance, 
and  the  staring,  foolish  look  disappeared  in  marked  degree. 

She  was  able  to  sleep  soundly  not  only  at  night,  but  took  a  long, 
refreshing,  restful  sleep  every  day  in  addition  to  regular  sleep  at  night. 
Better  digestion  was  soon  followed  by  marked  growth  and  improved 
general  appearance.  When  school  opened  in  September  she  was  so 
much  quieter  and  under  such  good  control  that  it  was  possible  for  her 
to  attend  classes.  Her  concentration  was  then  such  that  she  could  take 
piano  lessons  for  one  hour  at  a  time,  and  was  willing  to  continue  longer 
if  desirable. 

The  following  year  she  was  sent  to  a  private  school  and  her  progress 
has  been  gratifying. 


CHAPTER  XII. 

MALFORMATIONS,  DISEASES,  AND  INJURIES  OF  THE 

LIPS. 

MALFORMATIONS   OF  THE  LIPS. 

In  perversion  of  fetal  development,  closure  of  the  fissure  that  enters 
into  the  formation  of  the  mouth  may  cause  absence  of  the  mouth 
opening,  astomia,  of  partially  obliterated  mouth  opening,  the  result 
being  microstomia,  or  unduly  small  mouth. 

Failure  to  close  to  the  usual  degree  leads  to  macrostomia,  or  abnor- 
mally large  mouth. 


B^ 

■ 

^^^L^^ 

^H 

^B 

I^H 

^H'^'   1 

m 

^H         1 

^^\"?^ 

^^^^P^^'             ^ 

HH||Ek«4|yf 

I^^K'„    ..fl 

^^H^^H 

^^^^^HHkmHI^B 

Fig.  368. — Macrocheilia. 


Accidental  injuries,  cicatricial  contractions  resulting  from  destructive 
lesions,  surgical  operations,  and  similar  agencies  may  cause  complete 
closure  of  the  opening  of  the  mouth.  Its  size  may  be  similarly  reduced 
or  enlarged  to  such  an  extent  as  to  require  operative  correction. 

Macrocheilia  denotes  abnormal  or  excessive  size  of  the  lips.  Lym- 
phangioma of  the  lips  is  the  usual  cause,  but  it  sometimes  occurs  in  cre- 
tinism, and  under  certain  conditions  of  abnormal  trophic  changes  (see 
p.  317).  Figs.  368,  369  and  370  are  photographs  of  some  of  the  author's 
cases  of  macrocheilia  which  present  interesting  diagnostic  features. 
Fig.  371,  showing  angioma  of  the  lip,  is  given  to  facilitate  comparison 
of  these  two  affections. 

(573) 


574        MALFORMATIONS,  DISEASES,  AND  INJURIES  OF  LIPS 


Labial  ectropion  and  deficiency  of  vermilion  border  may  be  con- 
genital, or  these  defects  may  occur  in  many  ways. 

The  author's  experience  in  operations  upon  the  opening  of  the 
mouth  and  lips  leads  him  to  believe  that  little  could  be  gained  by 
detailed  description  of  the  different  operations  recommended  for 
stomatoplasty  (plastic  surgery  of  the  mouth).  In  actual  experience 
he  has  found  that  there  is  too  great  variance  in  the  conditions  and 
requirements  of  such  cases  to  warrant  reliance  upon  any  single  method. 
The  principles  upon  which  both  selection  of  method  and  operative 
technic  must  depend  are  included  in  the  descriptions  of  operations 
upon  the  lips  and  restorations  of  the  oral  opening  following  operations 
for  the  removal  of  malignant  growths  in  the  region  of  the  mouth,  as 
elsewhere  described  (p.  485). 


Fig.  369. 


-Lymphangioma  of   the   upper 
lip. 


Ftg.  370.  —  Lymphangioma  of  the 
upper  Up.  (Another  view  of  same  girl 
shown  in  Fig.  369.) 


Fissures  of  the  Face,  Lower  Lip,  and  Lower  Jaw. — Lip  fissm-es 
are  sometimes  associated  with  clefts  that  extend  more  or  less  obliquely 
through  the  face  (Fig.  372). 

Fissure  through  the  lower  lip  and  jaw  is  rare,  but  sometimes  occurs 
in  the  region  of  the  first  branchial  arch.  It  is  due  to  failure  of  union 
in  the  two  inferior  maxillary  arches.  It  may  be  simply  a  fissure  in  the 
lower  lip  or  extend  completely  through  the  lower  jaw  also. 

Clefts  of  the  face  and  jaw  occur  too  infrequently,  and  the  lives  of 
infants  with  extensive  clefts  are  usually  too  short  to  warrant  an 
attempt  to  outline  a  proper  treatment  of  such  cases.  If  such  an  infant 
were  endowed  with  sufficient  life  to  continue  its  existence,  operative 
procedures  might  be  indicated  and  would  necessarily  be  undertaken 


MALFORMATIONS  OF  THE  LIPS 


575 


to  correct  the  deformity  in  such  form  as  it  might  appear;  but  clefts 
of  the  upper  Hp  and  palate  occur  so  frequently,  and  so  much  is  at  stake 
in  the  restoration  of  appearance  and  speech  power,  that  the  subject 
of  their  correction  is  worthy  of  most  careful  consideration.  The 
subjects  are  so  interwoven  that  it  seems  best  to  treat  them  together 
in  a  separate  chapter. 


Fig.  371. — Angioma  of  the  upper  lip.     (Westmoreland.) 


Fig.  372. — Complete  bilateral  fissure  (coloboma)  of  face.     (Guersant.) 


Diseases  affecting  the  mucous  membrane  (see  p.  151)  affect  the 
prolabium,  and  diseases  of  the  skin  may  manifest  themselves  upon 
the  surface  of  the  lips.  These  insofar  as  they  directly  concern  our 
subject  have  been  described  in  other  chapters. 


CHAPTER  XIII. 
HARELIP,   CLEFT  PALATE,   AND    DEFECTS   OF    SPEECH. 

HARELIP  AND  CLEFT  PALATE. 

Classification. — In  classification  of  these  cases  three  principal  divi- 
sions require  recognition,  because  they  govern  operative  procedures  and 
results.  These  are  the  character  of  the  deformity,  its  form,  and  the 
age  of  the  patient.    They  are  considered  in  the  following  classification : 

Character. — (a)  Congenital;  (6)  acquired. 

Form. — (a)  Fissure  in  velum  palati  only;  (h)  fissure  of  the  velum, 
including  part  of  the  hard  palate  also;  (c)  cleft  entirely  through  both 
hard  and  soft  palates;  (d)  median  fissures  through  both  hard  and  soft 
palates,  with  bifurcation  at  the  premaxilla;  (e)  double  separation 
divided  by  the  vomer,  including  the  hard  palate,  with  wide  fissure 
almost  completely  obliterating  the  velmn. 

Age. —  (a)  At  birth  or  during  early  infancy;  (b)  six  months  to  one 
year  old ;  (c)  two  years  old  and  during  the  period  after  deciduous  teeth 
have  been  erupted,  but  before  their  permanent  successors  have  caused 
them  to  loosen;  (d)  twelve  to  eighteen  years  of  age,  or  later  years, 
after  permanent  teeth  have  been  erupted,  but  before  developmental 
processes  have  been  completed;  (e)  adults  with  teeth  in  upper  jaws; 
(/)  adults  with  edentulous  upper  jaws. 

Either  lip  or  palate  may  be  imperfect  without  the  other  being 
affected,  although,  as  will  be  noted  by  study  of  the  illustrations,  it  is 
common  for  certain  forms  of  lip  and  palate  deformities  to  be  associated. 

Congenital  harelip  deformities  are  usually  either  unilateral  (see 
Figs.  373,  375,  377,  379  and  381)  or  bilateral  (see  Figs.  394  to  410), 
although  median  fissures  like  that  shown  in  Fig.  340,  p.  553,  sometimes 
occur.  The  fissures  may  be  of  first  degree,  or  little  more  than  a 
notch;  of  second  degree,  with  a  fissure  extending  completely  through 
both  lip  and  maxillary  bones;  or  of  third  degree,  a  wider  separation 
with  unilateral  protrusion  of  the  intermaxillary  bone. 

Bilateral  or  double  harelip  has  usually  marked  deformity  of  the 
vomer  with  protrusion  of  the  premaxilla.  To  these  must  be  added 
the  cases  that  have  been  imperfectly  operated  on  in  early  life.  These 
often  call  for  correction,  and,  although  presenting  an  indefinite  variety 
of  imperfections,  they  have  nevertheless  certain  characteristic  defects 
that  admit  of  distinct  recognition,  and  may  be  enumerated  as  fol- 
lows: (1)  Notch  at  the  labial  border;  (2)  deflection  of  the  tip  of  the 
nose,  with  deviation  of  the  cartilaginous  septum  and  flatness  of  the 
ala  on  the  affected  s^ide;  (3)  unsightly  scars;  (4)  stenosis  of  one  or  both 
(576) 


HARELIP  AND  CLEFT  PALATE 


577 


nares;  (5)  marked  arrest  of  development  due  to  removal  of  the  pre- 
maxillary  portion  of  the  jaw;  (6)  lip  too  long,  and  drawn  under  the 
incisor  teeth,  so  that  it  sometimes  is  between  the  teeth  when  the  jaws 
are  closed. 


Fig.  373. — Single    harelip    (first    degree). 
Very  slight  defect  without  cleft  palate. 


Fig.  374. — ^The  same  child  as  shown  in 
Fig.  373  after  operation. 


Fig.  375. — Harelip  (first  de- 
gree). This  child  had  fissure 
of  the  velum,  but  the  hard  pal- 
ate was  almost  complete. 


Fig.  376. — Same  child  shown  in  Fig.  375  after 
both  lip  and  palate  fissure  have  been  closed  by 
operations. 


Etiology. — ^The  chief  recognized  etiological  factors  in  harelip  and 
cleft  palate  deformities  are  direct  heredity  and  hereditary  tendency, 
metabolism,  maternal  impressions  and  position  in  utero,  and  patho- 
37 


578  HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

logical  affections  of  the  female   generati^•e  organs  which   may  affect 
the  form  of  the  o\  um. 


Fig.  377. — Harelip  (second  degree). 
The  fissure  in  this  case  extended 
through  both  hard  and  soft  palates. 


Fig.  378. — The  child  shown  in  Fig.  377 
after  operations.  Both  lip  and  palate  fissures 
have  been  closed. 


Fig.  379. — Infant  -w-ith  single  harelip  (third  de- 
gree) and  wide  fissure  through  both  hard  and  soft 
palates,  showing  characteristic  deformity  of  nose 
and  mouth. 


Fig.  380. — Same  baby  at  eight 
months,  after  lip  and  hard  palate 
have  been  closed  as  described. 


Direct  Heredity. — Direct  heredity  plays  a  part  in  the  general  resem- 
blance of  the  offspring  to  its  more  or  less  immediate  ancestors,  and 


HARELIP  AND  CLEFT  PALATE 


579 


also  in  tlie  transmission  through  various  members  of  the  same  family 
of  peculiar  deformities  or  other  variations  from  so-called  normal  types 
of  both  form  and  mental  characteristics,  but  this  fact  is  not  so  generally 
apparent  as  was  formerly  believed.  The  author's  records  of  a  very 
large  number  of  cases  with  family  history,  so  far  as  could  be  secured 
through  three  generations,  show  approximately  10  per  cent,  of  hare- 
lip and  cleft  palate  cases  in  which  one  or  more  individuals  in  the  same 
family  had  similar  defects,  either  in  the  present  or  a  previous  genera- 
tion. That  there  is  some  greater  law  governing  development  and 
maldevelopment  is  apparent. 


Fig.  381. — ^Harelip  (third  degree).  Wide  fis- 
sure through  both  hard  and  soft  palates. 


Fig.  382. — The  same  child  shown  in  Fig 
381  after  operation  upon  the  lip. 


Hereditary  Tendency. — This  includes  a  very  much  larger  group,  as 
indicated  by  maldevelopment  in  form  and  predisposition  to  disease 
through  imperfect  cell  activity. 

Maternal  Impressions. — There  is  reason  to  believe  that  maternal 
influences  may  effect  the  unborn  child,  but  absolutely  authentic  cases  in 
which  this  cause  might  be  the  true  etiological  factor  appear  to  be  com- 
paratively few.  The  author's  records,  which  seem  to  agree  with  the 
records  of  nearly  all  others,  show  almost  invariably  that  the  accident 
or  occurrence  which  was  alleged  to  have  frightened  or  impressed 
the  mother's  mind  during  pregnancy,  and  thus  "marked"  the  baby, 
upon  investigation  was  found  to  have  occurred  much  later  than  would 
make  the  production  of  this  particular  deformity  possible. 

Metabolism. — This  is  always  an  important  influence,  though  its 
significance  depends  upon  its  being  subject  to  or  in  precedence  of 
other  factors. 


580    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

Position  of  Child  in  Utero. — The  theory  of  abnormal  crowding  for- 
ward of  the  head,  preventing  union  of  the  parts  at  an  early  stage  of 
development,  appears  to  be  difficult  of  exact  proof. 


V 

pp-^         r,. 

m 

m''       '"^"^ 

<i 

>>^ 

Fig.  383. — Harelip  and  cleft  palate  with  unusual 
deflection  of  the  septum  for  a  case  in  which  the 
fissures'were  not  wide.  11 


Fig.  384. — Same  baby  as  in 
Fiff.  383  after  operation  on 
lip. 


Fig.  38.5. — Boy,  aged  fourteen  years, 
with  harelip  and  cleft  palate.  Shows  the 
increase  of  the  deformity  that  occurs  when 
such  cases  are  neglected  untU  advanced 
stage. 


Fig.  386. — ^The  same  boy  as  in  Fi?. 
385  after  both  lip  and  palate  have  been 
closed. 


Family  Histories.— In  the  majority  of  cases  the   family   histories 
upon  one  side  or  the  other,  and  sometimes  both,  disclose  in  direct  line 


HARELIP  AND  CLEFT  PALATE  581 

of  descent,  diseases,  deformities,  mental  states,  or  peculiarities  that 
are  now  recognized  as  indications  of  unstable  nervous  systems.  Many 
have  a  neurotic  tendency;  all  betray  unequal  cell  distribution  either 
in  peculiar  mental  or  nervous  habit,  or  asymmetrical  bodily  develop- 
ment. Consanguinity  is  undoubtedly  important  when  marriage 
between  closely  related  individuals  is  shown  by  the  family  histories 
of  these  infants. 

The  Hypophysis. — The  pituitary  body  and  particularly  its  glandular 
portion,  the  hypophysis,  appears  to  bear  a  more  or  less  important 
relation  to  this  and  other  deformities.  It  has  been  demonstrated 
in  many  ways  that  this  body  exerts  an  influence  over  body  growth 
and  the  related  structiues;  other  endocrine  organs  undoubtedly  share 
in  developmental  control. 

Pathological  Affections  of  the  Female  Generative  Organs. — Prof. 
Bardeen,  of  the  University  of  Wisconsin,  has  called  attention  to  the 
effect  of  deforming  the  ova  in  causing  monstrosities  or  lesser  deform- 
ities in  animals.  He  has  suggested  that  any  misplacement,  defective 
form,  or  inflammation  of  the  uterus  or  its  appendages,  that  might 
cause  the  hiunan  ovimi  to  be  compressed  or  otherwise  distorted,  may 
cause  deformity  of  the  child. 

Early  Treatment  of  Infants. — From  the  very  hour  of  birth  the 
question  of  the  manner  of  treatment  of  these  infants  becomes  all- 
important.  There  is  immediate  necessity  for  determining  whether 
early  radical  operation  for  closure  of  the  palate  first  and  lip  afterward 
shall  be  followed,  or  whether  more  conser^•ative  methods  will  yield 
greater  safety  and  better  results;  upon  this  decision  rests  for  good 
or  ill  the  entire  life  experience  of  the  individual.  The  author  is  con- 
vinced that  radical  operation  for  the  purpose  of  closure  of  palate  fissure 
in  early  infancy  by  immediate  forcing  together  of  the  maxillary  bones 
is  exceedingly  harmful  and  unnecessarily  dangerous.  It  leads  to  imper- 
fect future  results  which  appear  in  both  defective  speech  and  facial 
deformity.  This  opinion  is  based  upon  the  observation  at  different 
ages  of  a  very  large  number  of  cases  which  have  received  this  early 
treatment.  The  author's  system,  to  the  perfection  of  which  he  has 
devoted  many  years,  is  designed  to  accomplish,  by  gradual  steps 
the  readjustment  of  the  malformed  facial  features  and  the  closure  of 
both  hard  and  soft  palates  sufficiently  early  to  prevent  the  formation 
of  imperfect  speech  habits.  The  results  of  this  treatment  are  shown 
in  the  form  of  actual  photographs  of  individual  cases,  not  in  drawings. 
These  have  been  chosen  to  represent  the  types  of  congenital  deform- 
ities and  defects  due  to  ill-devised  operative  procedures,  with  a  view 
also  to  avoid  unnecessary  repetition. 

Claims  of  Advocates  of  Early  Operation  Harmful. — ^The  author  does 
not  agree  with  the  WTiters  who  fa^'0^  early  operations  upon  infants' 
palates.  They  claim  that  the  most  desirable  time  for  operation  is 
within  three  months  after  birth,  and  that  there  is  less  nervous  shock 
because  the  nervous  system  of  the  child  is  not  well  developed  and  the 


582    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

child  is  not  capable  of  receiving  the  same  unpressions  that  it  would 
later  in  life.  This  is  in  a  measure  true,  but  other  adverse  conditions 
incidental  to  palate  operations  often  more  than  counter-balance  purely 


Fig.  387. Infant  with  very  wide  fissure  through  lip  and  hard  and  soft  palates,  also 

marked  nasal  deformity. 


Fig.  388.— Same  chUd  as  shown  in  Fig.  387  at  four  years  of  age  after  the  lip  and  palate 
operations  have  been  completed.  The  final  operation  was  performed  when  she  was  two 
years  old.     Tendency  toward  correct  development  may  be  noted. 

nervous  considerations  in  newborn  children.  Likewise,  he  does  not 
believe  that  in  such  cases  the  bony  and  soft  tissues  develop  naturally 
according  to  accepted  types  and  thus  allow  speech  to  follow  when  the 


HARELIP  AND  CLEFT  PALATE  583 

child  reaches  speaking  age.     The  reasons  why  he  considers  such  state- 
ments erroneous  and  harmful  are  as  follows: 

Estimates  of  Early  Infant  Mortality  under  Operation  Misleading. — 
While  it  is  admitted  that  during  the  first  few  days  after  birth,  before 
the  nervous  mechanism  has  had  time  to  become  sufficiently  organized 
to  transmit  pain  acutely,  little  or  no  anesthetic  is  necessary,  and  that 
a  newly  born  infant  does  sustain  operation  fairly  well  under  some 
circumstances.  At  the  same  time  it  must  be  remembered  that  esti- 
mates of  mortality  in  early  operation  must  necessarily  be  misleading. 
Many  infants  do  not  live  beyond  the  periods  of  infancy,  many  die  from 
inanition  in  spite  of  good  care  and  carefully  selected  nourishment, 
even  though  no  surgical  operation  be  attempted,  and  it  is  hardly 
reasonable  to  suppose  the  percentage  of  fatalities  would  be  decreased 
by  the  addition  of  a  "surgical  operation  in  every  case. 

In  the  development  of  the  human  embryo  there  is  coincident  develop- 
ment of  other  parts  at  the  stage  which  determines  the  form  and  char- 
acter of  lip  and  palate.  Causes  which  lead  to  arrest  of  development 
in  this  particular  region  frequently  cause  arrest  of  development  in 
other  parts  of  the  individual.  Many  infants  placed  under  the  author's 
care  or  brought  to  his  notice  have  had  additional  fingers  or  thumbs, 
or  they  have  been  totally  deaf  from  birth,  or  otherwise  defective. 
Internal  defects  are  manifested  in  low  vitality.  One  or  more  of  the 
organs  of  the  body  may  be  unable  to  perform  natural  functions  with 
sufficient  energy  to  sustain  life,  and  this  is  entirely  exclusive  of  the 
difficulty  in  taking  nourishment,  which  can  be  temporarily  overcome 
by  the  application  of  strips  as  described  (p.  592),  or  operation. 

Susceptibility  to  Toxemias  in  Infancy. — The  total  deaths  in  the  city 
of  Chicago  during  one  year  was  27,212;  of  these,  .5631  were  under  one 
year,  or  more  than  one-fifth  of  the  whole  number  of  deaths  of  all  ages 
and  from  every  cause. 

Certainly  grave  surgical  operations  during  the  first  few  weeks  or  even 
months  would  not  have  reduced  this  number  of  infant  deaths.  Emi- 
nent investigators  have  amply  proved  that  there  is  a  vastly  greater 
resistance  to  disease  and  injury  of  every  kind  after  one  year  than 
previously. 

Order  of  Closing  Lip  and  Palate  when  Both  are  Involved. — It  may  be  in 
a  measure  true  that  with  lip  fissure  open  operation  may  be  more  easily 
performed  upon  the  palate,  but  no  one  accustomed  to  operate  in  this 
field  has  serious  difficulty  in  securing  all  the  space  necessary  for  rapid 
use  of  suitable  instruments  in  cleft  palate  operation  after  the  lip  has 
been  properly  closed.  On  the  other  hand,  the  correct  adjustment  and 
fixation  of  the  maxillary  bones  in  their  right  relation,  with  the  addi- 
tional advantage  of  better  circulation  for  the  nourislunent  of  flaps 
which  is  secured  by  proper  fip  closure,  are  important  factors  in  leading 
to  successful  results  w^hen  the  palate  operation  is  performed. 

Permanent  Deformities  of  Face.— In  addition  to  the  danger  of  early 
operations,  serious  permanent  disfigurement  of  the  nose  and  face  is  a 


584         HARELIP,  CLEFT  PALATE.  AND  DEFECTS  OF  SPEECH 

matter  of  some  moment,  for  interference  with  development  of  the 
teeth  must  affect  the  form  of  the  maxillary  bones  and  other  osseous 
portions  of  the  face,  thus  directly  influencing  the  shape  of  the  nares, 
the  orbits,  and  the  palate.  It  is  axiomatic  then  that  violent  injury 
of  any  kind  in  early  infancy,  even  though  for  the  good  purpose  of  palate 
closure,  should  only  be  a  dernier  ressort,  and  at  best  cannot  fail  to  exer- 
cise a  very  serious  and  deplorably  ill  effect  on  the  appearance,  the  gen- 
eral health,  and  the  character  of  the  voice  of  the  individual  so  treated 
(see  Figs.  435,  437,  439,  440,  441,  443,  448,  449,  452,  453,  456,  458  and 
462). 

At  the  fifth  week  of  embryonic  life  the  germs  of  developing  teeth 
have  already  begun  to  assume  distinctive  form,  and  at  birth  both 
deciduous  and  permanent  sets  are  far  along  toward  development. 
Interference  with  growth  of  the  maxillary  bones  affects  quite  seriously 
the  regular  eruption  of  these  teeth  in  due  form  at  the  proper  periods. 
The  successfully  erupting  dental  organs  if  malposed  by  early  disturb- 
ance alter  the  form  of  the  face,  the  oral  cavity,  the  nares,  the  orbits, 
and  more  indirectly  the  development  of  the  individual  in  such  manner 
as  to  demand  most  careful  consideration  before  surgical  procedures 
are  attempted.  Development  of  the  posterior  portion  of  the  palate 
in  such  cases  tlu'ough  the  newgrowth  of  the  upper  jaw,  back  of  the  first 
molar  tooth,  does  sometimes  show  a  tendency  to  proceed  along  normal 
lines.  The  incisor,  cuspid,  and  even  bicuspid  regions,  however,  must 
of  necessity  suffer  arrest  of  development  in  marked  degree  from  the 
previous  compression  of  the  maxillse  upon  each  side  of  the  fissure  in 
early  infancy. 

Any  injury,  in  fact,  that  disarranges  the  occlusion  of  the  growing 
upper  teeth  so  that  they  erupt  in  lingual  instead  of  buccal  or  labial 
occlusion  with  their  antagonists  in  the  lower  jaw  will  have  the  same 
effect. 

Nasal  Stenosis. — Stenosis  of  the  nares  is  also  a  vital  matter  in  con- 
sidering the  effect  of  ill-advised  operations  upon  development.  Those 
familiar  with  the  A'arious  typical  forms  of  palate  fissvire  know  that  in  a 
large  proportion  of  cases  it  is  physically  impossible  to  close  the  cleft 
by  immediate  pressure  of  any  kind  without  bringing  the  opposite  sides 
of  at  least  one  naris  in  absolute  contact,  and  in  any  case  the  nasal 
opening  must  be  very  much  narrowed  upon  one  or  both  sides  (see  Figs. 
440,  443  and  450). 

The  question  of  partial  or  complete  stenosis  of  the  nasal  passages 
and  the  natural  ill-results  of  mouth-breathing  concerns  general  as  well 
as  local  development  and  general  health  besides.  Partial  nasal  im- 
provement may  occur,  but  there  can  never  be  a  normal  condition  in 
that  region.  The  proof  of  this  statement  is  at  hand  everywhere, 
for  in  otherwise  normal  individuals  the  relations  of  contracted  dental 
arches  and  high  palatal  vaults  to  mouth-breathing,  enlarged  turbinates, 
spurs,  hypertrophic  and  atrophic  rhinitis,  are  too  well  understood 
and  too  apparent  in  daily  rhinological  practice  to  admit  of  further 
question. 


SURGICAL  TREATMENT  OF  HARELIP  585 

Effect  upon  Speech. — This  leads  to  the  final  claim  for  better  speech. 
Individuals  affected  by  nasal  catarrh  do  not  have  good  speaking 
voices,  nor  do  those  who  are  mouth-breathers  with  marked  nasal 
obstructions,  nor  do  those,  as  a  rule,  with  contracted  irregular  dental 
arches  and  abnormally  high,  contracted  palates.  Not  only  is  this 
true  because  of  the  very  considerable  part  borne  in  word  and  sound 
making  by  those  influences,  but  in  such  cases  the  larynx  and  vocal 
cords  are  subject  to  affections  which  are  not  favorable  to  the  best 
speech  or  oral  result. 

The  development  in  form  and  character  of  the  soft  palate  is  not 
as  good  as  by  later  operation.  More  perfect  plastic  work  may  be  done 
by  the  surgeon  in  proportion  as  he  may  with  safety  to  his  patient  be 
deliberate  in  his  effort  to  secure  perfect  coaptation  of  surfaces  with 
exact  muscular  alignment  of  opposing  muscles.  Probably  nowhere 
in  the  whole  field  of  surgery  is  this  more  important  than  in  staphylor- 
rhapy.  The  chief  battle  at  any  age  is  so  to  control  hemorrhage  and 
other  disadvantageous  conditions  which  tend  to  increase  the  difficulty 
of  operation  in  this  necessarily  somewhat  awkward  situation,  as  to 
make  accuracy  practicable  notwithstanding  the  radical  measures  that 
are  imperatively  required  to  secure  the  best  results. 

Reasons  Why  Skilful  Surgeons  Often  Fail  in  Those  Operations.— 
The  chief  difficulty  of  present-day  surgery  of  the  face,  lips,  jaws,  and 
palate  lies  in  failure  to  grasp  the  underlying  principles  of  development 
in  this  region,  and  want  of  appreciation  of  the  proper  relation  of  asso- 
ciate parts  in  their  influence  upon  the  form  and  character  of  these 
special  divisions  of  this  field  of  practice. 

Large  nmnbers  of  cases  have  come  to  the  author  with  history  of  one 
or  more  previous  unsuccessful  operations.  Quite  frequently  it  has 
been  evident  that  the  general  surgical  skill  of  the  operator,  who  never- 
theless failed  to  secure  a  good  result,  was  of  high  order,  but  not  having 
recognized  some  apparently  slight  though  really  unportant  factor, 
the  postoperative  deformity  was  greater  than  the  congenital  one. 

SURGICAL  TREATMENT  OF  HARELIP. 

Principles.  —  1.  The  first  principle  of  all  plastic  operations,  and 
particularly  cheiloplaMy  in  any  form,  is  that  it  is  useless  to  attempt 
to  secure  a  good  cosmetic  result  by  adjustment  of  the  soft  tissues 
alone,  because,  however  perfectly  this  may  be  done  at  the  time  of 
operation,  the  future  form  must  inevitably  be  determined  by  the 
outline  of  the  underlying  supporting  structure. 

2.  The  second  and  almost  equally  important  principle  is,  that  with- 
out due  recognition  and  suitable  adjustment  of  muscular  attachments 
and  care  as  to  the  direction  of  muscular  fibers  in  uniting  surfaces,  the 
form  of  the  lip  will  be  correspondingly  altered. 

3.  No  matter  how  great  the  temptation  may  be  to  displace  tissue 
for  the  purpose  of  closing  a  lip  fissure,  such  a  procedure  must  be  avoided 


586  HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

if  possible.  Even  though  the  immediate  appearance  at  the  time  of 
operation  may  be  better  by  so  doing  than  if  direct  approximation 
had  been  secured  by  forcing  the  separated  parts  together  in  what 
would  have  been  their  normal  relation,  the  final  result  will  be  much 
more  perfect  in  the  latter  than  in  the  former  case.  With  the  parts 
displaced,  as  development  proceeds,  asymmetry  and  the  consequent 
unnatural  appearance  will  be  increased.  On  the  other  hand,  even 
though  temporary  deformity  results,  when  the  parts  are  attached 
in  such  manner  as  to  lead  to  natural  physiological  action,  they  will 
continue  to  improve  as  time  goes  on  because  de^'elopment  along  right 
lines  is  thus  made  possible.  The  interdependence  in  such  develop- 
mental relation  of  the  mouth,  nares,  jaws,  and  bones  of  the  face,  and 
the  co5rdination  of  muscular  action  as  affecting  both  function  and 
expression,  thus  alters  not  only  the  appearance  of  the  face  and  lips, 
but  of  the  eyes  as  well,  and  in  almost  equal  degree.  These  facts  have 
been  set  forth  at  some  length  in  other  chapters  touching  this  subject. 

These  principles  are  quite  elementary,  and  are  not  brought  forward 
as  being  in  any  sense  original,  but  their  application  in  the  guidance 
of  operative  procedures  is  not  as  generally  observed  as  it  should  be, 
nor  is  their  far-reaching  influence  upon  future  development  sufficiently 
recognized  by  surgeons.  All  agree  that  the  final  result  absolutely  and 
inevitably  depends  upon  symmetrical  growth.  Examples  of  this  are 
everywhere  noticeable  among  persons  whose  lips  bear  evidence  of 
operative  procedures  in  closure  of  harelip,  and  are  daily  object  lessons 
when  one's  practice  is  almost  wholly  confined  to  patients  of  this  class. 
Many  of  the  deeply  scarred  lips,  deformed  noses,  and  distorted  faces, 
with  typical  staring  appearance  of  the  eyes  at  the  time  of  operation,  in 
infancy  undoubtedly  appeared  as  though  the  operation  were  eminently 
successful,  but  succeeding  years  brought  steadily  increasing  deformity. 

The  final  test  of  a  successful  lip  operation  must  not  alone  be  a  smooth 
skin  surface,  with  the  greatest  possible  freedom  from  scar  tissue  and 
nicely  adjusted  vermilion  border,  although  these  are  matters  of  vital 
importance  and  worthy  of  the  utmost  possible  effort  to  secure  them. 
In  even  greater  degree  it  is  important  that  the  nose  be  in  proper 
alignment  and  capable  of  natural  respiratory  function,  that  the  teeth 
when  erupted  be  in  good  form,  and  that  muscular  attachments  be 
correctly  adjusted.  The  supreme  tests  would  then  be  nasal  respira- 
tion, and  expression  when  the  individual  smiles  or  laughs.  It  is  a 
notable  fact  that  many  lips  which  have  a  good  appearance  in  repose  are 
distorted  during  laughter,  and  unless  there  is  an  abundance  of  tissue 
on  the  under  side  of  the  lip,  the  tightness  induced  by  muscular  action 
under  these  conditions  renders  the  defect  particularly  and  often  un- 
pleasantly noticeable  (Figs.  389  to  394). 

The  Difficulties  in  Cheiloplasty. — ^The  adverse  conditions  to  be  over- 
come in  correction  of  harelip  are: 

Tension. — ^Tension  as  the  intervening  fissure  is  overcome  by  stretch- 
ing the  parts  across. 


SURGICAL  TREATMENT  OF  HARELIP 


587 


Maldevelopment. — Maldevelopment   of    the    projecting   premaxilla, 
which  tends  to  widen  the  fissure  and  make  its  closure  more  cUfficult. 


Fig.  389. — Infant  with  harelip  and  complete 
eleft  palate.  The  nose  has  been  partially  straight- 
ened, and  the  fissures  made  narrower  by  wearing 
an  adhesive  strip  as  described. 


Fig.  390. — The  same  child  as  in 
Fig.  389,  at  the  age  of  two  and  one- 
half  years,  after  both  lip  and 
palate  have  been  closed. 


Fig.  391. — The  same  child  shown  in 
Figs.  389  and  390.  Test  of  the  operative 
result  during  laughter. 


Fig.    392. — Another  view  of    the  same 
child  as  in  Figs.  389,  390  and  391. 


Nasal  Deformity. — Nasal  deformity  due  to  distorted  development 
in  the  maxillary  region,  which  carries  with  it  deflection  of  the  attached 
vomer  and  nasal  septum.    Through  this  agency  and  because  of  the 


588  HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

abnormal  muscular  action  thus  engendered,  when  the  fissure  extends 
through  into  the  nose,  the  triangular  cartilage  is  also  deflected.  The 
abnormal  situation  of  the  detached  maxillary  bones  through  adverse 
muscular  action  draws  the  cartilaginous  wing  in  such  form  as  to  leave 
it  flattened  and  sometimes  curved  in  the  "UTong  direction. 

Irregularity  of  the  Dental  Arch. — If  the  situation  of  the  premaxilla 
is  not  corrected  in  early  life  the  maleruption  of  teeth  in  this  region  will 
inevitably  increase  the  deformity.  If  in  an  eft'ort  to  restore  the  pre- 
maxilla to  its  natural  position  forcible  methods  are  applied  through 
traumatic  injury  to  the  developing  teeth  germs,  there  may  be  failure 


Fig.  393. — Later  picture  of  child  shown  as  an  infant  and  at  two  and  one-half  years 
old  in  Figs.  389  to  392.  Symmetrical  nasal,  labial,  and  facial  form  gives  proof  of  the 
correctness  of  the  principles  herein  set  forth  with  regard  to  early  treatment. 

of  certain  teeth  to  erupt,  in  which  case  maxillary  development  will  be 
arrested,  or  otherwise  perverted,  and  irregularity  of  the  teeth  will  be 
brought  about.  In  either  condition  there  will  be  deformity  which 
must  tend  to  increase  instead  of  decrease  as  the  individual  gets  older. 
Operative  Defects. — Imperfect  adjustment  of  the  prolabium,  lead- 
ing to  the  following  results:  (a)  Notch  or  V-shaped  space  at  the  lower 
border  of  lip;  (6)  one  side  higher  than  the  other;  (c)  excess  of  tissue 
causing  projection  beyond  the  proper  line;  (d)  a  white  surface  extend- 
ing upon  the  mucous  membrane  of  the  prolabium;  {e)  naris  upon  the 
affected  side  unusually  large  or  too  small;  (/)  the  transverse  or  other 
scars  which  stiffen  and  mar  the  appearance  of  the  lip;  {g)  depression 


SURGICAL  TREATMENT  OF  HARELIP 


589 


along  the  line  of  attachment;  {h)  unusual  broadness  across  the  base 
of  the  nose,  excessive  development  of  the  triangular  cartilage  leading 
to  marked  enlargement,  a  perpendicular  groove  through   its  central 


Fig.  394. — Infant  with  double  harelip;  shows  characteristic  projection  of  the  premaxilla, 
and  philtrum  of  the  upper  lip. 


Fig.  395. — Same  infant  as  in  Fig.  394  with  adhesive  strip  adjusted  to  reduce  the 
deformity  as  described  in  the  text. 

portion  or  tipping  down  to  its  under  surface;  {i)  in  double  harelip 
cases,  depression  in  the  premaxillary  region,  flattened  appearance 
of  the  nose,  displacement  of  the  parts,  so  that  the  small  portion  of 
upper  lip  tissue  (the  philtrum)  which  is  usually  attached  to  the  pro- 


590 


HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


jecting  premaxilla  becomes  part  of  the  nose  instead  of  the  hp,  unusual 
length  of  the  upper  lip,  which  is  then  drawn  downward  and  in\A'ard 
and  is  associated  with  a  beak-like  appearance  of  the  nose,  unusual 
length  to  the  upper  lip  with  bulging  forward  in  its  central  portion  and  a 
tightly  drawn  appearance  at  the  red  border;  (j)  altered  appearance 
of  the  eves  in  all  of  these  cases.     The  unnatural  tension  of  malmus- 


FiG.  396. — Same  infant  as  in  Figs.  394 
and  395.  Front  view  before  operation 
shows  the  benefit  derived  from  wearing 
the  adhesive  strip  for  about  ten  days. 


Fig.  397. — Same  infant  as  in  Figs.  394, 
395  and  396.  Profile  view  before  opera- 
tion shows  the  improvement  made  by  the 
strip  of  adhesive  plaster  worn  across  the 
lip  for  ten  daj's. 


Fig.  398. 


-Infant  with  double  harelip  deformity  reduced  by  wearing  an  adhesive  strip 
across  the  lip  ready  for  operation. 


cular  action  causes  a  strange  staring  of  the  eyes.  Occasionally  this 
is  so  marked  as  to  effect  the  supra 'Orbital  tissues  also.  Thus  one 
eye  may  appear  to  be  higher  than  the  other,  and  there  is  quite  often 
an  appearance  of  exophthalmos,  which  is  due  to  surrounding  structures 
rather  than  to  any  peculiar  form  of  the  eyeball  (see  Figs.  435  to  457). 

Methods  for  Overcoming  Difficulties. — It  is  the  author's  purpose 
to  present  a  clear  description  of  his  methods  for  overcoming  the  fore- 


SURGICAL  TREATMENT  OF  HARELIP 


591 


goiiio;  difficulties.     Part  of  the  technic  is  original,  part  the  adaptation 
of  other  methods. 


Fig.  399. — Infant  with  double  harelip. 


Fig.  400. — Same  infant  as  in  Fig.  399 
after  lip  operation.  In  this  case,  when 
the  palate  was  closed  one  j-ear  later, 
the  teeth  were  found  to  be  erupting  quite 
normally. 


Fig.  401. — Double  harelip  and  cleft  palate  Fig.  402. — Same  infant  shown  in  Fig. 

401  after  both  lip  and  palate  have  been 
closed,  and  deformitj-  corrected. 


Operation  to  Close  Lip  Fissure  on  Day  of  Birth  or  Soon  After. — If  it  be 
practicable  to  get  the  child  immediately  or  within  the  first  few  days 


592 


HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


after  birth,  it  is  of  great  advantage  to  perform  the  Up  operation  at  that 
time.  In  this  way  widening  of  the  fissure  is  prevented,  and  a  newborn 
infant  sleeps  so  much  of  the  tune,  that  there  is  very  little  tendency  to 
disturb  the  sutures  and  cause  irritation  or  later  scars. 


Fig.  403. — Infant  with  double  harelip. 


Fig.  404. — Same  ^  tii  i  mer  operation. 
Both  lip  and  palate  fissures  have  been 
closed. 


Fig.  405. — Infant  with  double  harelip. 


Fig.  406. — Same  ease  as  shown  in  Fig.  405. 


The  Use  of  Zinc  Oxide  Adhesive  Strip. — If  very  early  operation  can- 
not be  performed  then  the  simplest  and  most  effective  method  of 
accomplishing  this  is  by  the  adjustment  of  a  strip  across  the  lip,  as 
shown  in  Fig.  395.  When  the  fissure  had  been  sufficiently  narrowed 
and  the  premaxilla  brought  around  and  backward  into  approximately 
normal  situation,  it  will  be  noticed  that  marked    improvement  in 


SURGICAL  TREATMENT  OF  HARELIP 


593 


nasal  form  has  also  taken  place.     Whatever  this  treatment  may  not 
have  accomplished  in  the  direction  of  nasal  improvement  must  be 


Fig.  407. — Infant  showing  characteristic 
deformity  in  double  harelip. 


Fig.  408. — Same  child  as  ;:.  :-  .i 
Fig.  407  after  both  lip  and  palate  have 
been  closed  by  operations.  Eight  months 
after  operation  on  Up 


Fig.  409. — Boy,  aged  four  years,  ^\-ith  double 
harelip  and  cleft  palate.  Shows  increase  of  the 
deformity  as  the  child  became  older. 


Fig.  410. — Same  boy  as  in  Fig. 
409  after  excision  of  a  section  of 
the  vomer,  and  correction  of  the 
deformity. 


done  at  the  time  of  operation.    Therefore  operative  procedm'es  must 
include  provision  for  this  result  (Figs.  396,  397  and  398). 
38 


594         HARELIP,  CLEFT  PALATE    AND  DEFECTS  OF  SPEECH 


SURGICAL  TREATMENT  OF  HARELIP 


595 


S  ft 


<5  5 


2S 


S  CI 
S.2 


^^ 


590         HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


SURGICAL  TREATMENT  OF  HARELIP 


597 


598    HARELIP,  CLEFT  PALATE    AND  DEFECTS  OF  SPEECH 

Nasal  Splint  and  Tension  Suture. — ^The  author  has  devised  a  suture 
(see  Fig.  424),  which  is  employed  in  such  manner  as  to  be  at  once  a 
nasal  splint  and  a  tension  suture  to  hold  the  nasal  septum  and  tri- 
angular cartilage  of  the  nose  in  correct  alignment,  the  cartilaginous 
wing  upon  the  affected  side  in  proper  form  and  situation,  and  the 
tissues  of  the  cheek,  lip,  and  facial  muscles  in  such  position  that  when 
severed  and  reattached  their  points  of  attachment  will  be  improved. 
While  doing  all  this,  tension  from  the  approximated  wound  surface 
is  relieved.  This  suture  is  of  the  same  form  as  that  which  he  uses  in 
cleft  palate  operations. 


Fig.  423. — ^The  author's  method  of  hareUp  operation.  The  illustration  shows  the 
author's  lip  olamp  in  position.  The  wire  suture  with  silver  plate  for  septum  splint, 
the  lead  suture  of  silk  or  linen,  the  adhesive  square  for  protection  of  the  skin  surface 
and  the  method  of  introduction  of  this  suture. 


A  needle  carrying  a  silkworm  gut,  or  as  formerly  used  a  silk  or  linen 
ligature  attached  to  a  wire  suture  is  passed  through  from  the  naris 
upon  the  opposite  side  if  the  case  be  one  of  single  harelip,  carried 
through  the  affected  naris,  and  brought  out  upon  the  cheek  a  little 
below  and  beyond  the  external  border  of  the  ala  on  the  affected  side 
(Fig.  423).    The  silver  plate  that  has  been  previously  attached  to  the 


SURGICAL  TREATMENT  OF  HARELIP 


599 


sutiire  is  changed  from  its  usual  square  shape  to  oblong  form,  its 
width  and  length  being  adjusted  to  fit  the  nose  so  as  to  prevent  buck- 
ling or  other  distortion  when  drawn  into  place  against  the  septum. 
At  the  point  where  it  is  drawn  through  the  cheek  a  square  of  zinc  oxide 
adhesive  plaster,  somewhat  larger  than  the  silver  plate  and  having  a 
small  hole  in  the  center,  is  slipped  over  the  suture  down  to  the  skin 
sm-face.  A  small,  square  silver  plate,  with  suitably  perforated  holes, 
is  again  passed  o\'er  the  suture  and  following  this  are  perforated  lead 
shot,  which 'can  at  a  proper  tiaie  be  compressed  and  thus  made  to  hold 
their  parts  in  their  proper  position  (Fig.  424).     This  simple   suture  is 


Fig.  424. — The  author's  method  of  single  harelip  operation.  The  wire  splint  and 
tension  suture  in  place  with  silver  plate  and  compressed  lead  shot  in  position.  Outline 
of  lip  incision.    Silkworm  gut  may  be  substituted  for  wire,  with  good  result. 

the  key  to  the  whole  situation.  It  not  only  holds  the  parts  in  proper 
relation  as  described,  but  when  tightened  gives  the  necessary  pressure 
to  control  the  severe  hemorrhage  which  sometimes  follows  the  free 
incisions.  The  latter  are  necessary  to  sever  muscular  attachments, 
and  it  is  of  the  utmost  importance  that  they  should  be  thoroughly 
and  extensively  carried  out,  thus  relieving  the  tension  of  muscular 
action  during  the  early  part  of  the  healing  process  and  affording  the 
readjusted  muscular  attachment  that  is  so  necessary  to  the  best  final 
result. 

Compression  of  Vessels. — The  hemorrhage  can  be  materially  reduced 
and  the  operative  steps  facilitated  by  making  compression   of  the 


600         HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

coronary  arteries.  The  author's  clamp  for  this  purpose  is  shown  in 
Fig.  423.     (See  Plate  XX.) 

In  infant  cases  the  double  clamp  shown  in  the  illustration  is  unneces- 
sary. Any  form  of  compressor  which  will  not  do  injury-  to  the  parts 
and  not  be  in  the  way  of  the  operator  will  do  equally  well.  In  adult 
cases,  however,  the  double  clamp  serves  the  purpose  of  controlling 
hemorrhage  with  less  pressure  than  a  single  clamp  sometimes  requires; 
it  also  serves  to  keep  the  two  sides  of  the  lip  extended,  and  in  this  way 
favors  accuracy  in  making  incisions  to  secure  correct  length  of  the  lip 
and  adjustment  of  the  border  of  the  prolabium.  The  weight  of  the 
attachment  also  assists  in  this  direction. 

Incisions. — As  may  be  seen  from  a  study  of  Figs.  411  to  422  inclusive, 
many  diilerent  forms  of  freshening  the  lip  fissure  borders  and  of  forming 
flaps  to  secure  the  necessary  adjustment  of  the  divided  lip  surfaces 
and  suitable  outline  for  the  prolabium  have  been  devised  and  advo- 
cated from  time  to  time  by  different  operators.  "Without  entering 
into  a  detailed  description  of  the  advantages  and  disadvantages  of 
each  one,  the  principle  already  referred  to  may  be  safely  depended 
upon  for  guidance,  namely,  that  any  incision  which  alters  the  normal 
relation  of  the  muscular  fibers  of  the  parts,  even  though  temporarily 
advantageous,  will  ultimately  destroy  the  natural  expression  and  form 
of  the  nose  and  lips. 

The  author's  incision,  shown  in  Fig.  424,  is  begun  at  points  upon 
each  side,  as  exactly  as  can  be  determined,  in  line  with  junction  of  the 
nose  and  lip,  and  carried  downward  through  the  full  depth  of  the  lip 
tissue  to  the  border  of  the  prolabiiun.  Care  must  be  taken  that  the 
knife  divides  the  skin  throughout  the  length  of  the  incision;  for  if 
any  part  of  the  mucous  membrane  along  the  fissure  is  left,  it  will  always 
remain  as  an  ugly,  red-looking,  offensive  scar.  The  slant  of  incision 
away  from  the  central  line  upon  each  side  depends  upon  the  length 
of  the  lip,  because  the  point  at  which  the  prolabium  is  reached  must  be 
so  located  as  to  allow  each  side  to  give  the  lip  its  proper  length  at  the 
line  of  union.  AVhen  such  flaps  are  turned  down,  as  shown  in  Fig.  425, 
it  will  be  found  that  they  are  much  too  long,  and  if  united  without  care 
in  their  adjustment,  will  result  in  an  unsightly  lump  or  unusual  length- 
ening of  the  lip,  as  may  be  found  in  many  cases  where  operation  has 
been  performed  without  due  regard  for  this  fact.  It  will  also  be  found 
that  there  is  a  strip  of  skin  included  in  each  flap.  If  any  part  of  this 
remains,  it  will  always  show  as  a  white  scar  in  the  red  border  of  the  lip. 

To  avoid  these  defects  and  at  the  same  time  to  prevent  the  removal 
of  too  much  tissue  which  might  result  in  the  unsightly  notch  that  is 
so  characteristic  of  these  cases  when  improperly  operated  upon,  and 
to  gi\e  sufficient  thickness  at  the  lower  border  of  the  lip,  to  retain  the 
natural  outward  curve,  the  knife,  in  excising  the  skin  and  the  slight 
amount  of  superfluous  tissue  that  may  be  in  the  flap,  should  be  carried 
at  a  slant  from  without  inward  and  toward  the  center. 

It  is  impossible  to  set  a  fixed  rule  for  the  allowance  that  must  be 


PLATE  XX 


/ 

/- 

/ 

^r^ 

^.                    \  / 

\^^ 

^^"~"-\'^"-/ 

5.C.A".'V 

\w^  ^^j^J 

J 

,x:a>^V-:- 

■fe^^^- 

/        '  ^ 

^'V^ 

v!SSw^ 

.    /esc. 

\ 

FA 

S.  C.  A.,  superior  coronary  artery  and  its  nasal  branches;  7.  C.  A.,  inferior 
coronary  artery;  F.  A.,  anastoniosis  of  tine  inferior  labial  and  submental 
branches  of  the  facial  arteries;  M,  M,  orbicularis  oris  and  depressor  anguli 
oris   muscles. 


SURGICAL  TREATMENT  OF  HARELIP 


COl 


made  in  the  way  of  surplus  tissue  at  this  point.    The  operator  must 
be  governed  hy  the  exigencies  of  the  particular  case. 

It  may  be  said,  however,  that  the  contraction  of  scar  tissue  along 
the  line  of  incision  should  not  be  great,  and  it  should  never  be  necessary 
to  make  allowance  for  it  in  anything  like  the  degree  that  some  writers 
indicate,  l^hortness  of  the  lip  and  notches,  as  a  rule,  result  from 
impr()i)er  allowance  for  the  corresponding  length  of  tissue  upon  oppo- 
site sides  of  the  fissure.  The  raw  lip  borders  are  next  split  sufficiently 
to  insure  thickness  which  will  prevent  depression  along  the  line  of  the 
scar  when  the  wound  is  healed. 


Fig.  425. — The  author's  method  of  single  harehp  operation.  Fissure  borders  denuded  and 
split.    The  prolabium  flaps  prepared  for  suturing.    The  first  control  suture  in  place. 


The  first  suture,  as  shown  in  Fig.  425,  is  so  placed  as  to  include  the 
nasal  branch  of  the  artery,  as  may  be  seen  by  reference  to  Plate  XX. 

This  suture  is  placed  well  back  into  the  skin  and  entirely  through 
the  lip  upon  each  side.  It  serves  the  temporary  purpose  of  controlling 
hemorrhage  at  this  time  and  holding  the  wound  surfaces  together,  so 
that  more  accurate  adjustment  can  be  made  at  the  lip  and  nasal 
borders.  This  suture  is  not  completely  tied  at  once,  but  is  left  so  that 
it  may  be  loosened  or  tightened  as  required ;  and  the  ends  are  tempo- 
rarily clamped  with  a  forceps.  The  lip  on  each  side  is  then  raised,  and 
with  a  broad  knife  or  scissors,  or  both,  the  muscular  attachment  is 
freely  severed.  Upon  the  side  of  the  fissure  this  must  include  freeing  the 
cartilaginous  wing  of  the  nose  as  completely  as  possible.     The  profuse 


602    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

hemorrhage  which  follows  these  incisions  is  instantly  checked  by 
pressure  of  the  assistant's  fingers  upon  the  cheeks.  The  suture  through 
the  nose,  which  up  to  this  time  has  been  lightly  clamped,  is  now 
tightened  by  forcing  the  silver  plate  upon  the  external  surface  farther 
in  upon  this  suture,  and  the  shot  compressed  to  hold  it.  This  invari- 
ably gi\'es  the  necessary  compression  to  check  hemorrhage,  and  may  be 
depended  upon  to  control  it  permanently. 

When  this  adjustment  is  completed  it  will  sometimes  be  fomid  that 
the  direction  of  the  first  sutiue  is  no  longer  suitable.  After  another 
suture  has  been  placed,  which  is  carried  through  the  skin  and  muscular 
tissues  upon  each  side,  but  does  not  include  the  mucous  membrane 
upon  the  buccal  side  of  the  lips,  which  may  be  accurately  adjusted 
and  left  as  one  of  the  tension  sutures,  the  first  sutiu-e  may  then  be 
removed. 


Fig.  426. — The  author's  method  of  single  harelip  operation.     Sutures  placed  along  the 
mucous  membrane  surface  of  the  lip. 

Before  the  final  adjustment  of  the  sutures  upon  the  anterior  surface 
of  the  lip  and  the  prolabiiun,  the  lip  is  everted  and  catgut  sutures  are 
placed  along  the  inside  of  the  lip,  as  shown  in  Fig.  426.  This  insures 
against  the  likelihood  of  infection  from  the  mouth,  because  the  mucous 
membrane  siufaces  close  quickly  when  properly  approximated.  It 
also  to  some  extent  takes  the  strain  off  of  the  external  sutures  and 
prevents  the  likelihood  of  their  cutting  or  marking  the  skin.  At  the 
same  time  it  serves  to  fix  the  outline  of  the  form  of  the  lip  so  that  the 
skin  sutiues  may  be  acciuately  adjusted. 

For  the  approximation  of  the  skin  siufaces  the  author  prefers  inter- 
rupted sutures.  Notwithstanding  the  claims  that  have  been  made 
for  the  subcuticular  sutiue,  it  does  not  seem  to  hold  skin  borders  with 
the  perfect  accuracy  required  for  the  least  possible  scar. 


SURGICAL  TREATMENT  OF  HARELIP 


603 


Except  where  fault  has  occurred  for  some  other  reason,  the  marks 
of  the  interrupted  sutures  have  been  seldom  found  such  as  to  cause 
an  unsightly  api)ea ranee  of  the  lip.  Usually  two  catgut  sutures  are 
placed  reasonably  well  apart  to  resist  the  first  effect  of  strain  along 
the  line  of  union.  Extremely  fine  cambric  needles,  the  smallest  size 
made,  with  silk  (or  2000  fine  linen)  fine  enough  to  permit  their  use,  are 
employed  to  coapt  the  skin  borders  accurately.  At  the  prolabiiun 
and  occasionally  at  points  in  the  skin  surface  the  author  uses  horse-hair. 
Its  chief  advantage  is  that  its  elasticity  sometimes  permits  accuracy  in 
its  use,  which  it  is  difficult  to  secure  with  a  non-elastic  suture  material. 
How  great  or  how  little  the  importance  of  this  may  be  is  to  some 
extent  a  matter  of  conjecture. 


Fig.  427. — Shows  diagonal  line  ofapprosimation.     Skin  sutures  in  place. 


The  floor  of  the  nose  should  be  as  carefully  fashioned  as  the  con- 
dition of  the  patient  and  the  circumstances  under  which  operation 
must  be  performed  will  permit.  It  must  be  remembered  in  this  con- 
nection that  many  of  these  infants  are  in  an  extremely  precarious 
condition,  so  much  so  that  the  time  element  is  of  vital  importance. 
By  dissecting  free  the  divided  tissue  upon  each  side  along  the  floor  of 
the  mouth  at  the  external  opening  of  the  naris,  one  or  two  sutures 
can  easily  be  placed  just  inside  and  close  to  the  external  opening. 
This  will  not  only  serve  to  gi\'e  greater  perfection  in  the  external 


604         HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

appearance  of  the  nose  and  lip,  but,  as  explained  later,  will  sometimes 
have  a  great  influence  upon  speech  also. 

The  situation  and  the  direction  of  the  line  of  union  as  affecting  the 
later  scar  should  be  borne  in  mind  when  the  incisions  are  made. 

The  author's  preference,  wherever  possible,  is  to  have  the  line  of 
union  slanting,  so  that  the  point  of  junction  at  the  prolabium  will 
not  be  directly  under  the  beginning  of  the  wound  at  the  nose.  Such  a 
scar  as  may  remain  under  these  circumstances  is  much  less  noticeable, 
and  is  less  likely  to  draw  the  lip  in  an  unsightly  way  during  laughter. 
Even  when  it  does  attract  attention  it  is  less  apt  to  suggest  immediately 
the  thought  of  harelip.  The  scars  of  accidental  lip  injuries  are  for 
many  reasons  less  objectionable  than  the  mark  of  a  congenital  defect, 
such  as  harelip  (Fig.  427). 

Treatment  of  Double  Harelip. — In  these  cases  there  is  great  difference 
in  the  appearance  and  corrective  requirements.  The  premaxilla  may 
project  in  such  manner  as  to  cause  great  deformity  and  be  difficult 
to  place,  or  the  portion  of  the  lip  attached  to  the  premaxilla  may  be 
so  small  and  of  such  poor  character  as  to  make  its  presence  difficult 
to  detect.  In  most  young  infants  the  vomer  and  nasal  sections  are 
yielding,  and  it  is  comparatively  easy  to  force  the  parts  into  fairly  good 
relation.  Occasionally  a  child  is  met  in  which  even  at  birth  consider- 
able ossification  has  taken  place.  Figs.  394  to  410  are  examples  of 
these  cases. 

Reduction  of  the  Premaxilla. — Were  it  not  that  cases  are  occasionally 
met  with  in  which  excision  of  the  premaxilla  has  been  comparatively 
recently  performed  to  facilitate  the  closure  of  double  harelip,  it  would 
seem  unnecessary  to  warn  against  this  practice. 

Its  results  may  be  seen  in  Figs.  448,  453  and  456,  and  these  examples 
might  be  repeated  almost  indefinitely  among  individuals  operated 
upon  according  to  older  methods. 

This  apparently  useless  and  often  embarrassing  Excrescence  projecting 
from  the  end  of  the  nose,  with  a  detached  portion  of  the  lip  upon  the 
upper  or  anterior  surface  even  in  the  newly  born,  contains  the  germs 
of  both  deciduous  and  permanent  central  incisor  teeth,  and  frequently 
the  lateral  incisors  also. 

The  loss,  misplacement,  or  traumatic  injury,  which  may  severely 
injure  any  growing  part  of  this  premaxilla,  will  cause  deforaiity  to 
mar  the  features  of  the  individual  for  life.  Adjustment  of  the  zinc 
oxide  adhesive  strip  has  already  been  described.  Figs.  394  to  410 
show  what  may  be  done  in  this  way.  When  such  a  strip  is  adjusted 
for  the  first  time,  pressure  with  the  ball  of  the  operator's  thumb  may 
be  employed  to  force  the  premaxilla  back  in  the  direction  of  its  proper 
situation.  In  older  infants  the  vomer  may  be  split  with  a  periosteal 
elevator  or  a  strong  knife.  This  separates  the  two  divisions  due  to 
its  double  development.  Pressure  on  the  premaxilla  causes  folding 
of  the  parts,  and  permits  proper  placement  of  the  parts  with  the  least 
possible  deformity.     By  cutting  diagonally,  the  parts  may  be  slid 


SURGICAL  TREATMENT  OF  HARELIP  605 

past  each  other  if  necessary,  as  adjustment  takes  place  and  no  tissue 
is  lost.  The  excision  of  a  V-shaped  portion  of  the  vomer,  as  commonly 
recommended,  will  almost  certainly  result  in  a  rabbit-shaped  mouth 
that  is  exceedingly  displeasing  in  appearance. 

Only  in  old  cases  where  the  vomer  has  become  thick  and  altogether 
excessive  (Figs.  409  and  410)  should  any  of  this  structure  be  removed, 
and  then  with  such  care  as  to  prevent  deformity  if  possible. 

Incisions. — Von  Langenbeck's  method  (Fig.  420),  or  some  modifica- 
tion such  as  the  Maas  and  Hagedorn  operations,  has  been  most 
generally  followed  by  surgeons  during  recent  years. 

In  this  way  the  premaxilla  is  preserved  and  a  portion  of  its  labial 
attachment  also,  but  another  kind  of  deformity  is  created.  The 
characteristic  appearance  of  patients  operated  on  according  to  this 
plan  may  be  noted  in  Figs.  449  and  452. 

During  infancy  the  results  in  these  cases  may  appear  to  be  all  that 
might  be  desired,  but  with  advancing  growth  a  progressive  increase 
in  objectionable  appearance  takes  place.  The  transverse  scars  of  the 
united  flaps  that  have  been  carried  across  and  joined  to  the  lower 
border  of  the  central  lip  segment  contract  or  at  least  yield  less  readily 
than  the  normal  structures.  The  effect  of  this  is  to  cause  the  anterior 
portion  of  the  maxilla  to  bulge  forward  and  the  scar  band  to  be  drawn 
downward  and  inward. 

In  many  patients  who  have  come  to  the  author  this  had  already 
caused  the  upper  lip  to  become  abnormally  long,  with  most  unsightly 
convexity  on  the  anterior  aspect. 

The  author  believes  that  every  portion  of  the  lip  tissue  on  the 
anterior  surface  of  the  premaxilla  should  be  preserved  if  possible; 
that  even  though  it  be  scant  in  size  and  thickness,  it  should,  neverthe- 
less, be  treated  as  though  it  were  the  full  lip  section  that  it  represents ; 
that  attempts  to  excise  it  completely  and  to  create  a  single  central 
line  of  union  almost  always  fail  to  give  a  good  result  in  later  life, 
because  of  the  alterations  that  are  created  by  attempted  natural 
growth;  that  if  properly  united  to  the  muscle  fibers  of  the  lateral 
portions  of  the  lip,  the  natural  function  thus  made  possible  will  lead  to 
proper  growth  and  development. 

There  may  always  be  a  disproportion  between  the  thickness  of  the 
central  and  lateral  portions  of  such  a  lip,  and  the  lip  so  treated  may 
remain  too  short  notwithstanding  its  increased  opportunities  for 
growth,  but  from  wide  experience  in  the  correction  of  lip  defects,  the 
author  unhesitatingly  states  that  such  a  lip  can  be  improved  in  later 
life  and  made  to  present  a  more  natural  appearance  than  a  mutilated 
lip  ever  can. 

Technic  of  the  Author's  Operation  for  Double  Harelip. — ^The  same 
kind  of  suture  that  has  been  described  with  reference  to  single  harelip 
operations  is  used  in  double  cases.  The  needle  is  inserted  just  outside  the 
ala  upon  one  side,  carried  through  the  nasal  septum,  and  out  upon  the 
opposite  side  just  beyond  the  ala.     The  skin  is  protected  with  squares 


006 


HARELIP,  CLEFT  PALATE.  AND  DEFECTS  OF  SPEECH 


of  zinc  oxide  adhesive,  and  a  silver  plate  is  adjusted  with  perforated 
lead  shot  clamped  upon  wire.  This  holds  nose,  cheeks,  and  lips  in 
correct  relation,  checks  hemorrhage,  and  relieves  the  principal  strain 
upon  the  sutures. 

In  other  respects  the  operation  is  performed  in  the  same  manner 
as  in  single  cases,  except  that  there  are  two  rows  of  sutures  instead 
of  one  (Figs.  428,  429  and  430). 

Great  care  is  sometimes  necessary  in  suturing  the  central  division 
of  the  lip  securely  to  the  lateral  portions  without  traumatic  injury  or 
interference    with   circulation   sufficient   to   cause    sloughing.     With 


Fig.  428. — Author's  method  of  do\il:)le  harelip  operation.  Splint  suture  for  retention  and 
correction  of  the  deformity  of  the  nasal  septvim  in  place.    Outline  of  the  incisions. 

perfect  control  of  the  situation  during  operation,  and  delicate  manip- 
ulation with  fine  needles  and  sutures,  such  a  result  may  never  occur, 
and  never  has  in  the  author's  experience,  except  years  ago  in  some 
of  his  earliest  cases  in  which  methods  advocated  by  others  were 
used. 

That  extensive  sloughing  may  follow  either  single  or  double  harelip 
operations  is  shown  by  Figs.  435,  437,  439  and  440.  These  cases  were 
brought  to  the  author  for  operation  after  such  failure  had  been  allowed 
to  take  place. 

Postoperative  Control  Strips  and  Dressings.- — ^The  author's  method  of 
stra})ping  infants  and  some  older  patients  after  harelip  operations  is 
illustrated  in  Fig.  431. 


SURGICAL  TREATMENT  OF  HARELIP 


607 


Fi(i.  429.— Author's  method  of  double  harelip  operation.      Fissure   borders   prepared 
for  the  sutures.     First  control  suture  in  place. 


Fig.   430. — Author's  method  of  double  harelip  operation.     The  operation  completed 

and  skin  suture  in  place. 


Fig.  431. — The  adhesive  strip  carried  from  the  cheek  upon  one  side  across  the  bridge 
of  the  nose  to  a  corresponding  point  upon  the  opposite  side  of  the  face.  Another  adhesive 
strip  attached  upon  the  cheek  upon  one  side  just  below  the  upper  strip,  and  carried 
across  the  chin  to  a  corresponding  point  upon  the  opposite  cheek.  Both  of  these  strips 
are  drawn  just  tight  enough  to  reUeve  tension  upon  the  Up  sutures,  and  the  lower  one 
is  so  adjusted  as  to  hold  the  lips  slightly  apart  to  favor  respiration  after  operation. 
(Author's  method.) 


Fig.  432. — Dry  sterilized  gauze  laid  lightly  across  the  lip  and  attached  at  each  end 
with  short,  narrow  adliesive  strips.  This  dressing  can  be  removed  whenever  necessary 
without  remo\dng  the  adhesive  tension  control  strips.     (Author's  metliod.) 


SURGICAL  TREATMENT  OF  HARELIP 


009 


A  strip  of  zinc  oxide  adhesive  as  wide  as  the  nose  is  long  is  carried 
from  the  cheek  on  one  side,  over  the  nose,  to  the  cheek  upon  the  other 
side.  It  is  then  drawn  tightly  enough  to  wrinkle  the  cheek  slightly 
and  firmly  attached.  A  second  strip  is  attached  to  the  cheek  upon 
one  side,  carried  over  the  chin  to  the  opposite  cheek,  with  care  to 
adjust  in  such  manner  that  the  lower  lip  will  be  kept  slightly  open. 
If  the  skin  surfaces  have  been  cleaned  and  dried  with  ether,  these 
adhesive  strips  will  hold  in  position  until  the  sutures  are  removed. 
The  dressing  is  laid  lightly  across  the  lip  and  attached  with  short, 
narrow  adhesive  strips.  This  may  be  removed  by  the  nurse  whenever 
it  becomes  soiled,  without  the  disturbing  retention  strips  (Fig.  432). 


Fig.  433. — Harelip  without  cleft  palate, 
except  fissure  through  the  alveolar  ridge. 
The  projecting  premaxilla  in  these  cases  is 
fixed  and  unyielding. 


Fig.  434. — -The  same  girl  after  forcible 
correction  of  the  deformity  and  closure 
of  the  lip. 


Treatment  of  Harelip  without  Cleft  Palate. — When  there  is  palate 
fissure  associated  with  harelip,  much  more  adjustment  and  improve- 
ment after  operation  may  be  expected  than  will  be  found  to  occur 
in  cases  in  which  the  hard  palate  is  complete,  except  for  the  single 
or  double  fissures  which  in  accordance  with  the  character  of  the  lip 
deformity  extend  through  the  alveolar  ridge. 

Surgeons  who  are  unaccustomed  to  these  cases  usually  operate  in 
the  belief  that  they  are  much  simpler  than  the  wider  and  more  difficult- 
looking  fissures,  that  include  both  lip  and  palate.  Error  in  this  respect 
has  led  to  many  postoperative  deformities.  The  real  difficulty  is  that 
the  premaxilla  always  projects  forward  more  or  less  in  the  same  manner, 
though  not  in  such  a  marked  degree,  as  with  the  former  class  of  cases. 
39 


610  HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

The  solid  resistance  of  the  full-formed  palate  behind  yields  less  readily 
to  action  of  the  lip  muscles  than  where  there  is  a  di\ision  which  gives 
greater  freedom  in  adjustment  of  the  misplaced  parts. 

When  children  have  passed  beyond  the  period  of  infancy  there 
must  always  be  a  definite  reduction  of  the  premaxilla  and  adjustment 
in  at  least  approxunately  correct  position  accomplished  by  surgical 
means. 

After  the  teeth  have  developed  the  parts  are  held  in  position  by 
wires  attached  to  the  teeth  or  metal  bands  are  cemented  upon  the 
tooth  cro\Mis,  to  which  is  attached  an  appliance  such  as  any  dentist 
might  construct  to  hold  the  parts  firmly  until  united.  In  most  cases 
it  is  better  to  do  this  at  a  preliminary  operation  and  later  to  close  the 
lip  perfectly,  when  there  will  be  no  likelihood  of  infection  of  the  lip 
from  the  mouth  wound.  This  was  done  in  the  case  of  the  patient 
illustrated  in  Figs.  433  and  434. 

A  deflected  nose  is  much  more  likely  to  persist  and  cause  a  less 
perfect  facial  appearance  than  in  other  cases. 

The  Removal  of  Scars  and  the  Correction  of  Postoperative  Lip 
and  Nose  Defects. — Naris  too  Large. — If  the  floor  of  the  nose  has  not 
been  properly  closed  in  conjunction  with  lip  or  palate  operation,  one 
naris,  or  even  both,  may  not  only  be  unsightly,  but  may  also  interfere 
with  speech  through  allowing  the  wTong  escape  of  air. 

In  these  cases  the  tissue  at  each  side  of  the  depression  or  fissiue  in 
the  floor  of  the  aftected  naris  may  be  incised  sufficiently  far  back  to 
allow  the  necessary  correction.  It  is  then  dissected  free  and  raised. 
Usually  the  septimi  will  be  deflected  in  single  cases,  and  the  large 
flattened  ala  also  require  reduction.  The  narrowing  effects  in  correc- 
tion of  these  associated  defects  allows  the  tissues  at  the  line  of  intra- 
nasal approximation  to  be  raised  in  such  a  manner  as  to  make  the 
parts  remain  permanently  in  corrected  position  when  united,  and  the 
floor  of  the  naris  to  be  correspondingly  benefited. 

The  characteristic  deflection  of  the  septum  resulting  from  failure 
to  care  for  this  defect  when  the  harelip  is  closed  the  author  corrects  by 
inserting  a  suture  with  splints,  as  described  for  harelip,  from  the 
opposite  side  of  the  septimi  and  put  through  the  cheek  just  beyond  the 
cartilaginous  wing  of  the  nose,  ^^^len  tightened  it  will  draw  the  sep- 
tmn  in  the  desired  direction.  The  upper  lip  is  then  raised  and  a  cartil- 
age knife  passed  through  from  beneath  the  lip  and  the  septimi  divided 
at  its  attachment  with  the  superior  maxilla,  as  far  back  as  may 
be  required  to  correct  the  anterior  de^•iation.  It  is  then  drawTi 
into  position  and  fixed  with  a  wire  suture.  The  oral  opening  is 
so  small  that  when  the  lip  drops  back  into  position  it  is  practically 
closed. 

The  effect  of  this  treatment  mav  be  seen  in  Figs.  435,  436,  437  and 
438. 

In  most  of  these  cases  operation  is  performed  incidentally  to  the 
operation  for  removal  of  scars  and  other  objectionable  features. 


SURGICAL  TREATMENT  OF  HARELIP 


Gil 


The  Correction  of  a  Notch  or  V-Shaped  Space  at  the  Lower  Border  of  the 
Lip  and  Shortness  Resulting  from  Imperfect  Closure  of  the  Lip  Fissure. — 
Effort  should  be  made  to  preserve  the  prolaljium  as  nearly  intact  as 
possible.     This  may  not  ahvays  be  accomplished,  but  usually  results 


Fig.  4.35. — Child,  aged  two  and  one- 
half  years.  One-half  of  lip  and  palate 
almost  totally  destroyed  as  a  result  of 
attempted  closure  of  lip  and  palate  at  the 
same  time.  Forcible  compression  of  the 
side  of  the  palate  was  attempted  in  early 
infancy. 


Fig.  4.36. — The  result  of  closure  of  the  lip 
for  the  little  girl  shown  in  Fig.  435. 


Fig.  437. — Child,  aged  three  years. 
Lip  nearly  half  lost  by  operation  upon  both 
lip  and  palate  at  the  same  time  in  early 
infancy. 


Fig.  438. — Same  child  shown  in  Fig.  437 
after  closure  of  the  lip  fissure. 


quite  naturally  when  a  transverse  incision  is  made  and  the  lower  por- 
tion of  the  lip  is  drawn  down  until  the  transverse  line  is  converted  into 
a  perpendicular  one.     The  length  of  the  incision  for  the  elimination 


612    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

of  the  defect  will,  as  a  matter  of  course,  be  governed  by  the  amount  of 
lengthening  the  lip  requires. 

When  One  Side  of  the  Lip  is  Higher  than  the  Other  at  the  Border. — 
Usually  a  considerable  amount  of  scar  tissue  must  be  removed.  It  is 
the  author's  custom  when  removing  scars  of  the  lips  to  follow  the  scar 
upon  each  side  with  a  knife  until  it  is  dissected  out  as  completely  as 
possible.  Then  incisions  are  made  without  regard  to  scar  tissue  to 
effect  the  desired  unpro\'ement.  Almost  invariably,  when  this  scar 
is  dissected  out,  the  lip  is  much  more  easily  adjusted  to  its  proper 


Fig.  439. — Front  view  of  boy,  aged  four 
years,  for  whom  the  operation  of  forcibly 
closing  his  palate  fissure  and  attempting 
to  hold  the  parts  \^-ith  wire  and  lead  plates 
was  performed  in  early  infancy.  The  lip 
was  closed  at  the  same  operation.  Both 
lip  and  palate  sloughed  out  except  for  a 
small  bridge  of  tissue  which  fixed  the 
maxillarj'  bones  as  placed.  Not  only  did 
he  lose  almost  the  entire  lip  upon  one  side, 
but  the  deformed  shape  of  his  face,  which 
is  characteristic  of  the  result  of  these 
operations,  remains  permanently,  as  is 
plainly  shown  in  the  illustration. 


Fig.  440. — Profile  view  of  the  same 
boy  as  in  Fig.  439.  The  malposition  of 
the  maxillse  and  consequent  deformity 
of  the  nose  which  resulted  from  forcing 
these  bones  together  to  close  the  palate 
fissure  in  early  infancy  are  markedly 
apparent. 


position;  therefore  not  only  is  the  unsightliness  removed  by  excision 
of  scar  tissue  but  the  approximation  of  the  parts  is  favored.  Care  must 
be  taken  not  to  cut  completely  through  the  lip  if  it  can  possibly  be 
avoided,  because  this  invites  infection  from  oral  secretions  and  has  a 
tendency  to  produce  more  scar  tissue.  With  the  lip  tissue  thus  set 
free,  the  operator  must  be  guided  in  adjustment  of  the  parts  as  the 
indications  require,  and  this  can  only  be  accurately  determined  by 
drawing  them  into  contact  and  placing  and  replacing  them  in  the 


SURGICAL  TREATMENT  OF  HARELIP 


613 


desired   position  until  perfection   is  secured.     Set  rules  for  making 
incisions  in  such  cases  are  misleading,  and  implicit  obedience  to  them 


"^Wfe;      ^^ 


I 


I    ilB      I 


Fig.  441. — -Infant  with  double  harelip 
and  cleft  palate.  The  history  of  this  case 
before  coming  to  the  author  shows  that  a 
few  days  after  birth  an  attempt  was  made 
to  close  the  palate  fissure  by  the  use  of 
silver  wire  and  lead  plates.  The  wires 
sloughed  out  and  there  was  a  general  infec- 
tion, as  a  result  of  which  the  child  was  in  a 
very  critical  state  for  several  weeks  before 
recovery. 


Fig.  442. — The  same  baby  after  the 
lip  and  hard  palate  have  been  closed. 
It  will  be  seen  that  it  was  impossible  to 
get  as  perfect  a  result  as  might  have  been 
obtained  had  the  first  operation  not  been 
performed. 


Fig.  443. — Boy  whose  nose,  lip  and  palate  were  almost  hopelessly  deformed  by  com- 
pression and  wiring  his  maxillary  bones  to  close  a  palate  fissure  in  early  infancy.  It  will 
take  long  patient  work  to  even  partially  restore  the  shape  of  his  mouth,  and  one  or  more 
lip  operations  to  improve  his  appearance.  He  is  a  great  sufferer  from  nasal  disease,  as  is 
nearly  always  the  case  with  such  operative  results. 


almost  invariably  results  in  failure.    The  operator  must  be  controlled 
by  the  guidance  of  his  o\\ti  judgment. 


614    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

In  the  Excision  of  Excessive  Tissue  Causing  Projection  Beyond  the 
Pioper  Outline  of  the  Lip  Border  and  the  Shortening  of  a  Lip  that  is  too 
Long  or  Removal  of  Excessive  Size. — Such  cases  of  macrocheilia  are 
illustrated  in  Figs.  368,  3G9  and  370.  Great  care  must  be  exercised 
to  make  the  knife  follow  the  exact  outline  of  the  proper  curve  of  the 
prolabimii  at  its  junction  with  the  skin  border.     This  is  not  so  easily 


Fig.  444. — Lip,  nose  and  palate  de- 
formed by  compression  in  early  palate 
operation,  and  making  the  lip  too  Ion?  by 
carrying  flaps  across  the  philtram  as 
usually  performed  in  double  harelip  cases. 


Fig.  445. — Same  boy  shown  in  Fig. 
444  after  operation  to  shorten  and  restore 
lip,  and  forcing  the  premaxilla  forward 
with  appliances  attached  to  the  teeth 
according  to  orthodontic  methods. 


done  as  might  appear,  because  when  holding  the  lip  taut  while  the 
knife  is  dra^Mi  across,  the  form  will  be  changed  unless  this  alteration 
is  provided  for. 

It  is  the  author's  custom  to  mark  the  surface  with  a  very  sharp 
knife,  and  then  as  the  incision  is  deepened  the  first  marking  can  be 


Fig.  446. — Boy,  aged  nine  years.  Pre- 
vious history  shows  that  an  operation  was 
performed  in  early  infancy  in  which  an 
endeavor  was  made  to  close  the  palate  by 
the  use  of  ■\\'ires  through  the  jaws  and  lead 
retaining  plates.  This  failed  disastrously, 
and  was  followed  by  four  other  operations 
with  only  partial  success.  The  difficulties 
were  enormously  increased  by  the  effect  of 
the  early  infancy  operation. 


Fig.  447. — .Same  boy  as  shown  in 
Fig.  446,  after  lip  and  nose  have  been 
reconstructed  and  the  palate  fissure 
closed  by  two  operations.  It  was  nec- 
essary to  readjust  the  malposed  parts 
and  partly  close  the  palate  fissure  at  the 
first  operation,  and  to  complete  the 
closure  one  year  later.  Since  this  picture 
was  taken  he  has  been  for  several  j-ears 
under  treatment  by  his  dentist,  who  has 
been  endeavoring  to  bring  the  malposed 
teeth  into  proper  alignment.  (Author's 
article,  Ochsner's  Surgery.) 


followed.  In  most  cases  sufficient  excessive  tissue  can  be  removed 
and  the  mucous  membrane  so  cut  as  to  alow  proper  restoration  of  the 
form  of  the  lip  when  it  is  drawn  up  and  sutured  to  the  skin  border.  A 
scar  at  or  just  above  the  junction  of  the  skin  and  mucous  membrane 
which  properly  follows  the  outline  of  the  prolabium  will  not  be  distinctly 
noticeable  after  operation.     Not  much  can  be  done  with  transverse 


SURGICAL  TREATMENT  OF  HARELIP 


615 


scars  across  the  lips  except  in  cases  where  they  may  be  inchided  when 
the  lip  is  shortened  or  the  lip  so  formed  as  to  cause  it  to   have  an 


1 1'j.  445. — Bu\",  aged  seven  years. 
Shows  the  characteristic  facial  appearance 
after  the  removal  of  the  intermaxillary 
bone  in  operation  for  double  harelip. 


Fig.  449. — Front  ^-iew  of  same  boy 
show-n  in  Fig.  44S.  His  palate  was  closed 
in  early  infancy  with  what  appeared  to 
be  a  successful  operation.  The  res\ilt  at 
seven  j-ears  old  may  be  seen.  Complete 
stenosis  of  left  naris,  right  side  of  nose 
almost  absolutely  useless  for  breathing 
purposes,  although  probe  can  be  passed 
through.  Disproportion  between  the 
upper  and  lower  parts  of  the  face  and 
head  due  to  arrest  of  development. 
Voice  shriU,  high,  and  by  no  means 
perfect  in  pronunciation. 


1 

|Bi^    %« 

w 

m  i. 

^ 

k 

Fig.  450. — Front  \-iew  of  same  boy 
shown  in  Fiss.  448  and  449  after  operation 
for  the  correction  of  his  lip  and  facial  de- 
foots. 


Fig.  4.51. — Side  ^•iew  of  boy  in  Figs. 
448,  449  and  450  after  operation  for  the 
restoration  of  more  natural  lines  in 
profile. 


61 0 


HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


outward  roll,  such  as  is  often  seen  in  natural  lips  and  which  serves  to 
make  the  transverse  marks  less  noticeable.  One  must  always  guard 
against  making  the  lip  too  short.  Better  leave  too  much  and  correct  it 
afterward  if  necessary  than  to  take  away  too  much  tissue  and  spoil  the  lip. 
Depression  along  the  line  of  union  must  be  avoided  in  lip  operations 
by  splitting  the  tissue  upon  each  side  of  the  wound  so  that  there  may  be 
thickness  enough  to  overcome  the  result  of  cicatricial  contraction 
during  the  healing  process.  By  cutting  through  the  skin  with  his 
knife  on  a  slant,  so  that  there  will  be  a  slight  tendency  to  lap  when  the 


Fig.  452.— Face  of  boy,  aged  fourteen         Fig.  453.— Same  boy  as  Fig.  452.     Side 
years,  showing  in  front  view  the  result  of  view  of  the  deformity, 

imperfect  early  operation  for  double  hare- 
lip which  is  apparent  in  deformed  nasal 
form;  almost  complete  nasal  stenosis; 
arrest  of  maxillary  developments,  due  to 
loss  of  premaxillary  structures  and  ante- 
rior permanent  teeth;  upper  Hp  too  long 
and  badly  marked  with  deep  scars,  and 
eyes  staring  on  account  of  unnatural'mus- 
cular  tension. 

surfaces  are  approximated,  the  author  finds  that  there  is  less  tendency 
to  scar  appearance  than  when  perfectly  straight  incisions  are  made. 
After  careful  trial,  however,  he  has  demonstrated  that  a  very  great 
slant,  one  that  would  leave  an  exceedingly  thin  flap  of  skin  upon  the 
upper  side  to  spread  over  the  lower  one,  as  has  been  recommended  for 
skin  surface  approxunation,  is  disappointing  because,  in  spite  of  all 
precaution,  there  will  often  be  a  tendency  for  the  thin  edge  of  skin  to 
shrivel  up  and  leave  a  greater  scar  mark  than  would  have  resulted 
from  a  perfectly  straight  incision. 


SURGICAL  TREATMENT  OF  HARELIP 


617 


Fig.  454. — Side    view    of    boy    shown    in 
Figs.  452  and  453  after  operation. 


Fig.  455. — Front  view  of  the  same 
boy  as  in  Figs.  452,  453  and  454  after 
operation  on  hp  for  the  purpose  of  short- 
ening the  lip;  effecting  reattachment  of 
the  parts  in  more  nearly  normal  relation, 
and  the  removal  of  scar  tissue.  The 
improvement  in  expression  of  eyes  is  due 
to  correction  of  unnatural  muscular 
action. 


Fig,  456. — A  young  man  whose  lip  was 
operated  upon  in  early  infancy  without 
due  consideration  for  developmental  prin- 
ciples. 


Fig.  457.^^The  same  individual  shown 
in  Fig.  456  after  operation  upon  the  lip 
and  readjustment  of  the  deformed  parts. 


618 


HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


Fig.  458. — Characteristic  scar  with  notch 
following  harelip  operation. 


Fjg.  459. — Same  young  man  shown 
in  Fig.  458  after  correction  of  the  lip 
defect  and  closure  of  a  wide  fissure 
through  both  hard  and  soft  palates. 


Fig.  460. — -A  typical  result  from  compression 
and  injury  to  the  premaxilla  in  closing  double 
harelip  fissure  in  infancy  by  the  method  of  carry- 
ing flaps  across  under  the  phUtrum  as  commonly 
advocated. 


Fig.  461. — The  same  young  man 
(twenty-two  years  old)  who  is 
shown  in  Fig.  460  after  operation 
to  correct  the  form  of  the  nose, 
remove  scars  and  readjust  the  lip 
outline. 


Fig.  462. — Young  woman  whose  face, 
nose,  lip  and  mouth  have  all  been  deformed 
by  displacement  of  tissue  in  an  operation 
for  double  harelip  performed  in  infancy. 


i-r-V-  '■        1 

P.^^^ 

J 

ar^ 

'^''^^B 

^M 

m^. 

m 

r 

K. 

Fig.  463. — Same  young  woman  shown 
in  Fig.  462,  after  parts  have  aU  been 
restored  to  their  normal  situations,  and 
the  scars  removed.  More  than  all  else 
correct  muscular  action  and  respiration 
have  been  established.  Through  these 
agencies  there  has  been  a  continued 
improvement  in  her  features  and  the 
expression  of  the  face. 


SURGICAL  TREATMENT  OF  HARELIP 


G19 


A  Thick,  Broad,  and  Grooved  Triangular  Cartilage  of  the  Nose. — When 
this  is  such  as  to  be  unsightly  it  is  necessary  to  remove  a  certain 
amount  of  the  cartilaginous  tissue  to  give  the  nose  its  proper  shape. 
The  remo\'al  of  this  cartilage  should  be  effected  from  within  the  nose 


Fig.  464. — Shows  the  method  of  removing  the  excessive  tissue  from  the  triangular 
nasal  cartilage  in  such  cases  without  external  incisions.  Thus  avoiding  scar  disfigure- 
ment. 


Fig.  465. — Fixation  suture  in  place. 


with  fine  cutting  knives  and  a  fixation  suture  passed  completely  through 
the  nose  from  one  side  to  the  other,  to  hold  the  parts  in  form  until 
union  can  take  place.  This  is  a  common  deformity  among  adults 
who  were  operated  upon  according  to  old  methods  of  treating  harelip 


620    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

and  is  frequently  required  to  give  satisfactory  results  from  harelip 
correction. 

The  author  has  operated  upon  large  numbers  of  these  noses,  and 
the  results  are  usually  very  satisfactory. 

Situation  of  Scar.— When  choice  can  be  made  as  to  the  situation 
of  the  scar  following  lip  operation  it  should  be  remembered  that 
with  boys  it  is  best  upon  one  side.  If  a  double  fissure  has  existed, 
both  scars  should  be  kept  well  away  from  the  center,  so  that  in  later 
life  a  moustache  may  be  grown  which  will  cover  the  defect  altogether. 
With  girls  or  young  women  the  line  of  union  is  less  noticeable  in  the 
center,  through  the  philtrum  of  the  lip  or  along  one  or  both  of  the 
ridges  at  each  side  of  the  philtrmii. 


Fig.  466. — Notch   and   scar   from   imper- 
fect harelip  operation  in  infants. 


Fig.  467. — Same  man  shown  in  Fig. 
466  one  year  after  the  correction  of  the 
lip  defects  by  operation  to  lengthen  the 
lip  and  obliterate  the  notch,  as  well  as 
to  reduce  the  scar. 


Actual  photographs  of  cases  operated  upon  by  the  author  accord- 
ing to  the  methods  advocated  are  illustrated  in  Figs.  373  to  410,  and 
433  to  463  inclusive. 

These  pictures  are  intended  to  show  that  the  results  are  uniform. 
They  are  presented  in  considerable  number  and  variety  for  the  pur- 
pose of  demonstrating  the  clinical,  therefore  essentially  practical  value 
of  the  principles  which  underlie  the  operative  steps  that  have  been 
recommended. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE. 

Definitions. — Uianoplasty.- — Plastic  surgery  of  the  palate;  any  plas- 
tic operation  for  the  cure  of  cleft  palate;  usually  applied  with  reference 
to  the  hard  palate. 

Uranorrhaphy.— The  surgical  closure  of  a  cleft  palate,  especially  a 
hard  palate. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


621 


Staphylorrhaphy. — Surgical  closure  of  cleft  palate,  especially  of  the 
soft  palate. 

The  author  prefers  the  use  of  the  terms  uranoplasty  and  uranor- 
rhaphy in  the  description  of  operations  for  the  closure  of  the  hard 
palate,  staphylorrhaphy  for  closure  of  the  soft  palate,  and  the  term 
uranostaphylorrhaphy  for  closure  of  fissure  of  the  hard  and  soft 
palates. 

Present  methods  of  palate  closure  are  necessarily  founded  on  the 
groundwork  constructed  by  eminent  surgeons  who  have  contributed 
to  literature  the  results  of  their  efi'orts  in  this  direction.  Lemonier, 
in  1776,  was  probably  the  first  to  attempt  to  close  palate  fissures  by 
surgical  means;  he  was  followed  by  Eustache  in  1799,  von  Graefe  in 
1876,  Roux  in  1879,  Warren,  of  Boston,  in  1820.     Diffenbach,  Liston, 


Fig.  468. — Brophy's  method  of  wiring  for  cleft  palate:  O,  orbital  cavity;  M,  upper 
jaw;  L,  lower  jaw;  T,  tongue;  W,  W,  silver  wire  (note  its  relation  to  the  teeth  sacs  which 
must  be  damaged).!    (After  Treves.) 

Sir  William  Ferguson,  Sedillot,  Pancoast,  William  Garretson,  Wolf, 
Erdman,  Billroth,  von  Langenbeck,  Trilet,  and  a  host  of  great  sur- 
geons, past  and  present,  who,  despite  great  discouragement — for  this 
work  is  ever  discouraging  to  surgical  procedures  when  compared  with 
other  fields  of  operation — have  each  lent  some  share  of  personal  skill 
and  ingenuity  to  aid  the  perfection  of  the  operative  technic  necessary 
to  insure  the  ultimate  success  of  the  work. 

Necessary  concentration  of  the  results  of  study  of  the  literature 
of  cleft  palate  operation  prevents  detailed  consideration  or  mention 
by  name  of  many  other  authors  who  have  from  time  to  time  brought 
forward  suggestions  with  regard  to  these  operations. 


1  Treves:  Operative  Surgery,  Fig.  281,  p.  173. 


622         HARELIP,  CLEFT  PALATE.  AND  DEFECTS  OF  SPEECH 

Types  of  Operation. — The  recognized  distinct  types  of  operation 
from  which  one  may  choose  in  deciding  upon  a  method  of  palate 
closure  may  be  summed  up  as  follows: 

Compression. — By  this  is  meant  crowding  together  the  segments  of 
a  palate  divided  by  fissure  in  such  a  manner  as  to  force  the  parts  into 
contact.  This  method  was  recommended  for  young  infants  by 
Garretson  and  Brophy  (Fig.  468). 

Turning  over  the  Flaps. — The  soft  tissues  upon  one  side  of  the  palate 
surface  are  reversed  and  attached  to  the  opposite  side.  The  method 
is  recommended  by  Lane  for  young  infants,  and  by  Ferguson,  of 
Chicago,  for  persons  of  more  advanced  age  (Figs.  469  to  472). 


Fig.  469. — Lane's  method  of  removing 
mucoperiosteal  flap  from  hard  and  soft 
palate  upon  one  side  of  the  cleft,  and  tuck- 
ing the  edge  of  this  flap  under  the  mucosa 
through  a  slit  upon  the  opposite  side  of  the 
cleft.     (After  Eastman.) 


Fig.  470. — Edge  of  flap  tucked  under 
slip  upon  opposite  side  of  cleft  .and 
sutured.     (After  Eastman.) 


Carrying  in  and  Attachment  of  Outside  Flaps. — The  flaps  are  taken 
from  lips,  cheeks,  skin,  or  other  extrapalatal  surfaces,  and  the  attach- 
ment of  a  finger  or  other  expedient  of  this  character  is  designed  to 
bridge  the  fissure. 

Fracture  of  Palate  Bones. — This  method  consists  in  sawing  through 
the  palate  bones  from  behind  forward,  fracturing  with  forceps,  and 
wiring  in  such  a  manner  as  to  approximate  the  bony  fragments  suffi- 
ciently to  bring  the  soft  parts  together.  It  was  devised  by  Ferguson, 
and  earnestly  advocated  for  many  years  by  J.  Ewing  Mears,  of  Phila- 
delphia, who  did  so  much  for  the  advancement  of  oral  surgery,  which 
after  having  become  practically  obsolete,  was  improved  by  Roe  (Fig. 
473)  who  by  the  use  of  a  specially  formed  needle  holder  and  needles 
was  able  to  introduce  an  E  string  banjo-wire  suture  in  such  manner 
as  secured  very^goodjresults. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


G23 


Anterior  Ends  of  Flaps  Detached. — Detachment  of  a  flap  from  the 
anterior  portion  of  the  palatal  mucoperiostemn  and  carrying  it  across 
the  fissure,  as  advocated  by  Davies-Colley  (Figs.  474  to  476),  has 
undoubtedly  a  field  of  usefulness  in  certam  cases. 


Fig.  471. — Ferguson's  method:  A,  in- 
cision upon  nasal  side  of  palate  for  turning 
down  flap;  B,  incision  upon  oral  side  for 
loosening  of  mucoperiosteal  flap.  (After 
Ferguson.) 


Fig.  472.— Ferguson's  method;  the 
nasal  and  oral  mucoperiosteal  flaps  with 
raw  surfaces  apposing,  leaving  a  mucous 
covering  upon  nasal  and  upon  the  oral 
side  of  the  new  palate.     (After  Ferguson.) 


Fig.  47.3. — Fissures  of  the  hard  palate:  A,  preliminary'^  punctures  with  awl  to  give 
Une  for  chisel;  B,  incision  through  bone  completed  by  chisel;  C,  holes  bored  through  hard 
and  soft  palat«s  for  sutures;  D,  junction  of  hard  and  soft  palate;  E,  lateral  openings  sub- 
sequently filled  up  bj'  granulation. 1     (Brj-ant.) 

Mucoperiosteal  Flaps. — They  are  closed  by  lowering  the  palatal  arch 
and  sliding  the  flaps  on  the  bone  surface  in  such  a  manner  as  to  bring 
them  in  contact,  as  brought  forward  by  von  Langenbeck,  and  improved 
and  altered  from  time  to  time  by  other  operators;  this  method  may 
be  useful. 


1  American  Sj-stem  of  Dentistrj-. 


624         HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

Retention  Sutures  and  Appliances. — Subdivisions  of  these  methods 
bring  us  to  the  consideration  of  various  expedients  for  aiding  the 
retention  of  sutures,  such  as  the  tape-ribbon  of  ]\Iayo  (Fig.  477),  the 
wax  tape-ribbon  of  Sherman  (Fig.  478),  the  lead-plate  and  silver- wire 
attachment  of  Brophy,  rubber  or  aluminum  plates  for  protection  of 


Fig.  474. — Davies-Colley  operation  for 
cleft  of  the  hard  palate  with  flaps  (a,  b,  c,  d 
and  e)  marked  out.i     (After  Treves.) 


Fig.  47.5.  —  Davies-Colley  operation 
for  cleft  of  the  hard  palate.  Flaps  in 
position.      (After  Treves.) 


Fig.  476. — Mucoperiosteal  flaps  are  turned  inward  to  cover  the  fissure  and  sutured 
with  the  periosteum  upward  toward  the  floor  of  the  nose.  Another  flap  is  raised  with 
anterior  end  free  and  its  posterior  end  attached  by  a  pedicle,  this  is  carried  across  the 
palate  and  laid  with  its  raw  surface  upon  the  previously  attached  flap  and  united  to  a 
flap  carried  from  the  opposite  side.     (After  McCurdy.) 

the  palate,  as  recommended  by  several  writers,  silver  plates  and  wire 
as  used  by  the  late  Dr.  Fillebrown  and  modified  by  other  operators. 
Conclusions.^ — The  author's  consideration,  observation,  and  experi- 
ence, as  applied  to  selection  from  these  methods,  lead  to  the  following 
conclusions :  * 

'Treves:  Operative  Surgery,  p.  169. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


625 


Palate  Com-pression. — The  first  of  these  methods  is  unhesitatingly 
to  be  condemned.  Such  compression  necessarily  contracts  the  parts 
in  such  manner  as  to  narrow  the  nares  and  crowd  the  erupting  teeth 
out  of  place  or  totally  destroy  them.  Thus  it  leads  not  only  to  later 
disfigurement  through  disarrangement  of  the  dental  arch,  but  also 
to  loss  of  growth  and  development  of  mouth,  nose  and  face,  making 
impossible  the  best  speech  when  adult  life  is  reached,  and  preventing 
the  fullest  possibility  of  good  appearance. 

Unfortunately  these  cases,  when  apparently  successful  and  so 
reported,  sometimes  in  later  years  prove  to  be  more  seriously  damaged 
than  the  unsuccessful  cases  in  which  the  parts  have  drawn  apart  at  an 
early  date,  and  thus  to  some  extent  overcome  the  contraction. 


Fig.  477  . —  Charles  Mayo's  method. 
Unwased  tape  passed  under  flap.  Tape 
\s  tied  with  single  turn  and  secured  bj'  silk 
ligature.     (After  Eastman.) 


:  v^V-<q 


Fig.  478. — Sherman's  technic,  relaxa- 
tion incisions,  mattress  suttu-es,  tape 
impregnated  with  wax  and  iodine  encir- 
cling the  flaps  to  prevent  tension  upon 
sutures.  Relaxation  incisions  packed 
with  .5  per  cent,  iodoform  gatize.  The 
ends  of  the  tape  and  silk  ligatiu-e  cut 
short  and  turned  around  to  nasal  surface 
out  of  reach  of  patient's  tongue  tip. 
(.Aiter  Eastman.) 


Large  numbers  of  children  and  young  persons  who  ha\"e  had  palates 
closed  in  early  infancy  by  direct  compression  are  living  examples  of 
the  truth  of  this  statement  ''see  Figs.  441  to  449  >.  Deviated  nasal 
septa,  contracted  nares,  and  diseases  attendant  upon  these  conditions, 
extending  in  various  degrees  throughout  the  extent  of  the  nasal  mucous 
membrane;  affections  of  the  middle  ear;  mastoiditis  with  associated 
deafness;  contracted  palates  with  teeth  developing  toward  the  central 
portion  of  the  mouth,  with  almost  hopelessly  deformed  dental  arches 
and  insufficient  space  for  tongue  movement  in  speech,  fully  attest 
the  truth  of  this  conclusion. 
40 


626    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

Oyeration  on  Puyyies} — Additional  evidence  is  given  by  sections 
through  the  heads  of  puppies  aged  six  months.  They  have  been 
sectioned  so  as  to  show  definitely  and  with  absolute  perfection  exactly 
what  does  occur  in  alteration  of  intranasal  form  when  growth  of  the 
upper  maxillary  bones  is  arrested  so  as  to  interfere  with  the  normal 
width  across  the  palate.  It  is  immaterial  whether  it  occurs  through 
adenoids,  enlarged  tonsils,  mouth-breathing,  the  malocclusion  inci- 
dental to  irregular  dental  arches,  or  through  forcible  compression 
and  the  introduction  of  retaining  wires  or  otherwise.  In  greater  or 
lesser  degree  the  same  results  are  inevitably  produced,  and  there 
is  the  invariable  chain  of  pathological  conditions  which  affect  not  only 
the  local  structures,  but  general  health  and  development  as  well. 

Much  less  compression  was  applied  than  would  under  any  possible 
condition  be  necessary  to  force  the  sides  of  a  palate  fissure  in  contact 
with  cleft  palate  cases.  Therefore  the  ill-results  which  are  apparent 
in  the  sections  in  the  heads  of  these  dogs  (see  Figs.  362  and  363,  p. 
566)  might  reasonably  be  expected  to  be  much  greater  and  more  dis- 
astrous from  such  palate  operations  than  with  this  slight  compres- 
sion. 

Fla'ps  Inverted. — ^The  second  type  of  operation  (Figs.  469  to  472) 
the  author  also  believes  to  be  objectionable.  The  disturbance  of 
the  natural  anatomical  arrangement  of  the  tissues,  occasioned  by 
turning  the  periosteum  upside  down,  is  hardly  likely  to  cause  bone 
growth  to  take  place,  as  it  might  if  the  periosteal  surfaces  were  merely 
moved  across  and  brought  together  in  natural  position.  He  believes 
that  all  such  operations,  even  though  successful  in  giving  a  covering 
to  the  palate,  cause  formation  in  that  region  of  more  or  less  thickened 
fibrous  tissue.  While  this  tissue  may  yield  to  normal  expansion  as 
growth  proceeds,  and  thus  not  seriously  contract  the  width  of  the 
palate  or  nose,  when  developed  it  will  not  have  the  firm,  resounding 
properties  of  a  bony  palate,  nor  will  it  have  the  fixed  resistance  to  the 
attachments  of  the  muscles  that  is  necessary  for  proper  speech  function. 

The  author's  belief  is  founded  upon  observation  of  a  considerable 
number  of  cases  in  which  there  was  not  and  never  had  been  fissure 
tlirough  the  palate,  beyond  a  few  instances  of  bifid  uvula,  and  yet  these 
individuals  had  all  the  speech  defects  of  patients  with  complete  fissures 
through  both  hard  and  soft  palates.  Not  only  was  this  the  case,  but 
the'Jnability  to  profit  by  speech  training  seemed  to  be  fully  as  great. 
Careful  examination  disclosed  in  every  instance  that  though  union 
of  the  soft  tissues  of  both  hard  and  soft  palates  was  complete,  there 
had  been  an  arrested  development  of  the  palate  bones.  This  left  the 
hard  palate  short  or  with  the  outlines  of  a  notch  in  the  median  portion, 
which  would  have  been  a  cleft  palate  had  it  not  been  covered  by  soft 
tissue.  Such  cases  were  not  previously,  and  are  not  now  generally 
recognized,  as  is  evidenced  by  the  fact  that  in  several  instances  more  or 

'  For  description  see  page  564. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE  627 

less  persistent  electric  and  other  treatment  had  been  used  to  stimulate 
what  was  believed  to  be  an  insufficient  action  of  the  palate  muscles 
due  to  partial  paralysis.  As  a  matter  of  fact,  the  real  cause  lies  in  the 
alteration  of  the  fixed  attachments  of  the  muscles  of  the  velum  palati 
at  the  hard  palate,  so  that  proper  function  in  lowering  and  raising  is 
impossible,  and  for  this  reason  development  of  the  soft  palate  as  a  whole 
is  incomplete.  Operation  in  a  number  of  these  patients  has  led  to 
considerable  improvement,  but  the  trouble  is  so  insidious  and  yet  so 
difficult  to  overcome  that  any  operation  which  at  the  outset  contem- 
plates producing  a  similar  condition  should  be  avoided. 

Transplantation  of  Tissue. — The  introduction  into  the  mouth  of 
extraneous  tissue  of  any  character  is  now  knowTi  to  be  absolutely 
unnecessary.  Even  the  worst  forms  of  palate  fissures  can  be  closed 
without  resort  to  such  expedients  and  with  better  hope  of  function 
than  would  be  possible  even  if  operative  attempts  at  transplantation 
had  been  more  successful. 

Methods  of  Retention. — In  the  selection  of  methods  of  retention 
such  as  are  included  in  our  subdivision,  the  author's  experience  leads 
to  the  conclusions  that  certain  principles  must  be  observed  in  all  palate 
operations,  and  that  without  pro^'ision  for  them  no  retention  expedient 
can  be  successful.  If  these  operative  principles  are  duly  provied  for, 
it  makes  little  or  no  difference  how  retention  is  accomplished  or  what 
agent  is  used.  A  plan  which  may  be  successful  for  one  operator  may 
in  no  way  appeal  to  or  be  productive  of  good  results  for  another.  A 
mucoperiosteal  flap,  unless  relieved  of  the  chief  elements  of  tension 
by  operative  means,  cannot  be  successfully  held  by  any  retention 
appliance,  suture  or  other  similar  assistance.  If  there  be  tension  upon 
the  sutures,  they  will  tear  out;  if  there  be  undue  strain  upon  a  broader 
surface  which  cannot  tear  out,  there  will  at  least  be  pressure  which  will 
interfere  with  circulation  and  cause  sloughing;  thus  the  result  is  likely 
to  be  the  same. 

Rubber  or  aluminum  plates,  or  other  similar  appliances  to  protect 
against  pressure  after  operation,  are  quite  unnecessary  and  should  be 
avoided  on  the  ground  that  all  things  that  may  be  cumbersome, 
uncomfortable  for  the  patient,  or  difficult  to  keep  clean  are  contra- 
indicated.  Lead  plates  kept  for  any  considerable  length  of  time  in 
mouths  of  patients  are  not  desirable;  moreover,  the  covering  of  large 
surfaces  of  mucous  membrane  of  the  mouth  by  any  substance  which 
prevents  cleanliness  is  inadvisable. 

The  author's  conclusions  as  affecting  operative  methods  may  be 
summed  up  in  the  statement  that  the  real  basis  for  unprovement  in  the 
results  of  palate  operation  lies  not  so  much  in  a  new  method  as  in  the 
perfection  of  technic  and  the  steps  of  operation,  so  that  the  purpose 
toward  which  all  the  different  plans  are  directed  might  be  better 
accomplished. 

Throughout  all  cleft  palate  treatment,  from  the  first  care  of  young 
infants  until  the  final  closure,  whatever  the  age  may  be,  the  nasobuccal 


628 


HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


relation  should  be  a  foremost  consideration,  for  upon  favorable  nasal 
conditions  both  speech  and  development  depend. 

Decision  as  to  the  Method  of  Procedure. — If,  therefore,  the  surfaces 
of  the  palate  of  an  adult  on  each  side  of  the  cleft  are  broad  enough, 
and  the  angle  of  their  slant  sufficiently  acute  to  enable  the  borders 
to  be  brought  together  in  the  median  line  without  tension,  after 
making  due  allowance  for  incisions,  then  a  plastic  operation  alone  is 
indicated.  If  these  conditions  are  unfavorable,  then  the  bony  parts 
should  be  corrected  before  the  division  in  the  soft  tissues  is  closed. 

Reduction  of  Wide  Palate  Fissures  by  Maxillary  Operation. — Since 
direct  compression  Avithout  modifying  preparation  would  narrow  the 
nares,  the  author  has  devised  the  method  sho^Mi  in  Fig.  479.     By 


Fig.  479. — The  author's  method  of  bone  operation  to  reduce  the  width  of  unusually 
unfavorable  fissure:  a,  b,  nut  and  screw  bar,  and  bands  cemented  upon  the  teeth;  c,  lines 
of  cutting  to  weaken  the  bow  resistance.  It  is  only  in  very  unusual  cases  that  this  treat- 
ment is  required. 

cutting  through  the  malar  ridge  on  the  external  surface  of  the  upper 
maxilla,  and  again  behind  its  tuberosity,  with  additional  grooving  of 
the  bone  through  the  denser  external  wall  between  these  points  (Fig. 
479),  the  parts  will  yield  under  pressure  and  narrow  the  palate  fissure 
without  affecting  the  nasal  region  to  any  marked  extent.  The  form  of 
splint  shown  in  Fig.  479,  a,  b,  holds  all  parts  firmly  as  long  as  required 
to  give  security.  Fig.  497  is  a  photograph  of  the  mouth  of  a  patient 
after  this  operation  has  been  performed,  and  shows  the  splint  in  place. 
Operative  Essentials  in  Palate  Closure. — The  chief  considerations 
to  be  observed  in  uranoplasty  and  staphylorrhapy  are:  (1)  Position 
of  the  patient;  (2)  anesthesia;  (3)  control  of  mmiediate  hemorrhage; 
(4)  provision  for  control  of  secondary  hemorrhage;  (5)  access  to  field 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


629 


of  operation;  (6)  avoidance  of  injury  to  tissue,  particularly  the  perios- 
teum; (7)  preservation  of  blood  supply;  (8)  relief  of  tension;  (9)  char- 
acter and  adjustment  of  sutures;  (10)  control  of  adverse  muscular 
action;  (11)  prevention  of  septic  conditions;  (12)  preparatory  treat- 
ment; (13)  postoperative  care. 


Fig.  480. — Cleft  through  hard  and  soft  palate.  Whitehead's  mouth  gag  as  modified 
by  the  author  with  bar  across  the  front  of  the  mouth  removed,  bow  over  the  nose  and 
arms  clasping  the  teeth  on  each  side. 


Position. — With  the  patient  in  a  recumbent  position  and  the  shoulders 
raised  with  a  pad,  the  head  tipped  backward  and  to  one  side,  a  good 
view  of  the  field  of  operation  is  obtained;  blood  collects  in  the  pouch 
formed  by  the  pharynx  where  it  is  least  likely  to  be  inspired  and  most 
easily  cleansed.  The  author  finds  this  more  favorable  than  the  Rose 
position,  in  which  the  head  hangs  over  the  table,  because  the  parts 
are  viewed  directly,  and  this  makes  it  easier  to  get  correct  approxi- 
mation than  if  viewed  upside  down.     Moreover,  patients  sometimes 


630         HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

complain  of  much  discomfort  from  the  neck  muscles  after  long  opera- 
tions when  the  head  was  hung  over  the  table  and  not  been  properly 
supported. 

Anesthesia. — Ether,*vaporized_by  heat,  and  blown  through  a  tube 
into  the  back  part  of  the  mouth,  as  by  the  Gwathmey  apparatus  (Fig. 
13,  p.  33)  can  be  made  to  give  just  the  delicately  poised  anesthesia 
that  is  so  exceedingly  desirable  to  avoid  the  danger  of  blood  inspiration, 


Fig.  481. — The  author's  self-retaining  fixation  forceps  atlachea  to  hold  the  soft 
palate  taut  to  favor  perfect  operative  work  upon  the  fissure  border.  Paring  the  border 
of  the  fissure.  The  author  believes  that  a  palate  border  pared  and  split  is  more  depend- 
able for  a  secure  hne  of  union  than  one  split  and  not  pared. 

which  might  easily  occur  with  the  reflexes  entireh'  abolished  in  pro- 
found unconsciousness.  This  method  also  makes  it  possible  to  keep 
a  patient  on  the  border-land,  sufficiently  quiet  and  insensible  to  pain, 
with  a  minimum  of  danger  and  of  tendency  to  postoperative  or  other 
ill  effects  of  the  anesthesia. 

Access  to  Field  of  Operation.— To  obviate  the  disadvantage  of  the  bar 
across  the  Whitehead  gag,  which  interferes  with  work  in  the  anterior 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


631 


part  of  the  mouth,  the  author  has  had  this  gag  improved  by  removing  the 
objectionable  portion  and  substituting  two  arms  which  rest  upon  either 
side  of  the  palate  close  to  the  teeth.  They  occupy  practically  no  space, 
hold  the  appliance  rigidly  in  place,  and  leave  the  entire  field  absolutely 
free  (Figs.  480  to  488). 


Fig.  482. — Raising  the  mucoperiosteum  with  the  author's  periosteal  elevator,  the  knife 
being  passed  under  it  to  sever  resisting  attachments. 


The  tongue  holder  attached  to  the  gag  is  to  some  extent  adjustable, 
since  patients  at  different  ages  and  sizes  require  tongue  holders  of 
different  lengths. 

Another  improvement  is  the  addition  of  two  little  parts  that  slide 
down  over  the  horns  that  rest  against  the  palate.  These  additions 
make  the  gag  fit  the  mouths  of  exceedingly  young  infants,  and  the 
guards  upon  each  side  give  a  very  desirable  degree  of  steadiness  (see 
Figs.  489  and  492). 


632 


HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


Preservation  of  Blood  Supply. — Perhaps  no  part  of  stapliylorrhapy 
or  of  uranoplasty  requires  so  much  judgment  as  the  decision  with 
regard  to  sufficiency  or  insufficiency  of  vascular  supply  to  sustain 
the  tissue  when  carried  to  its  new  position. 

If  the  operator  does  not  do  an  extensive  and  radical  operation 
involving  the  free  loosening  up  of  all  tissue  upon  the  palatal  surface, 
he  is  almost  certain  to  suffer  failure  through  pulling  apart  of  the  wound 


Fig.  483. — Mucoperiosteum  raised  while  the  auLliuiri  knife,  safe  on  the  upper  side 
and  bent  to  a  suitable  angle,  is  used  to  sever  the  tissue  attachments  at  the  posterior  border 
of  the  hard  palate. 

surfaces.  If,  on  the  other  hand,  he  does  his  work  very  thoroughly, 
making  free  incisions,  and  completely  separating  all  tissue  adherent 
to  the  palate  surfaces,  the  danger  confronts  him  of  having  extensive 
sloughing  through  want  of  nourishing  blood  circulation.  Great  care 
and  judgment  are  also  required  to  avoid  undue  injury  to  vessels.  Plate 
I  (frontispiece)  is  designed  to  give  accurate  guidance  in  dealing  with  all 
imporiant  anatomical  structures  in  this  region. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


G33 


Tension  Relief  Incisions. — Incisions  in  line  with  and  near  the  gingival 
borders  of  the  pa  lute  upon  each  side  should,  if  possible,  be  above  the 
line  of  the  palatal  artery,  and  in  using  the  periosteal  elevator  it  should 
pass  under  the  vessel,  and  effort  should  be  made  to  raise  it  intact,  so 
that  there  may  not  only  be  less  hemorrhage,  but  better  cii'culation 
in  the  flap  as  well  (Fig.  484). 


Fig.  484. — A  straight  periosteal  elevator  passed  through  the  lateral  incision  under 
the  niucoperiosteum,  and  a  curved  one  simultaneously  forced  from  the  border  of  the 
fissure  to  raise  the  flap  with  the  least  possible  traumatic  injury. 


It  is  not  always  practicable  to  do  this,  especially  where  cases  have 
been  previously  operated  upon  and  the  parts  disarranged,  but  it  should 
be  borne  in  mind  and  accomplished,  if  possible.  In  the  same  way,  the 
vessels  passing  tlirough  the  foramina  at  the  anterior  palatine  fossa 
should  not  be  severed  in  the  effort  to  separate  tissues  from  the  bone 
in  that  region. 

These  incisions  are  only  called  for  in  more  or  less  extreme  cases. 

Objections  that  have  been  made  to  this  plan  of  relieving  tension 


634    HARELIP,  CLEFT  PALATE    AND  DEFECTS  OF  SPEECH 

fall  to  the  ground  when  confronted  with  conditions  in  which  through 
scarcity  of  tissue  failure  must  inevitably  result  unless  the  tension  be 
relieved. 

Incisions  upon  each  side  of  the  soft  palate  should  be  a  series  of  slight 
incisions  in  the  same  line,  with  the  tissue  held  on  the  stretch,  rather 
than  a  single  deep  continuous  incision  which  would  increase  the  danger 


Fig.  485. — -The  author's  method  of  inserting  the  principal  wire  retention  suture. 
The  illustration  shows  the  bronze  wire  suture  with  silver  plate,  attached  to  the  leading 
suture  as  inserted  with  the  author's  needle  and  caught  at  the  point  with  a  hook  for  this 
purpose. 


of  hemorrhage.  Care  should  be  taken  to  make  these  in  such  form 
that  a  packing,  if  it  is  necessary  to  insert  one,  would  be  retained  and 
effective  (see  Fig.  486). 

Sutures. — The  author  uses  formalized  pyoktanin  gut  for  coaptation 
sutures.  He  has  found  it  better  than  silk,  inasmuch  as  it  does  not  take 
up  the  oral  secretions,  and,  though  resisting  for  a  sufficient  time  to 
serve  its  purpose,  it  is  easily  absorbed,  and  unlikely  to  make  a  channel 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


635 


down  which  the  nasal  secretions  can  find  their  way  and  thus  create 
infectious  disturbance. 

Retention  sutures  are  of  silkworm  gut  or  as  formerly  used  aluminum 
bronze  wire.  This  the  author  believes  to  be  preferable  to  silver  wire, 
because  it  has  a  slight  degree  of  stiffness  which  prevents  its  pulling  taut 
and  in  that  way  cutting  the  tissue  at  each  side.     This  wire  is  passed 


Fig.  486. — Wire  tension  sutxire  in  place  -n-ith  silver  plate  slipped  over  its  free  end 
do'nn  to  the  palate  surface  and  followed  by  four  lead  shot.  Method  of  freeing  the  soft 
palate  tissue,  and  forcing  it  toward  the  center  through  the  lateral  incisions.  Pad  inserted 
as  used  to  control  hemorrhage. 


through  silver  plates  which  serve  to  relieve  the  tension.  Xo  matter 
what  the  form  of  plate  or  button  suture  may  be,  it  is  well  to  remember 
that,  after  all,  the  "«"ire  itself  would  cut  through  the  tissue  if  any  con- 
siderable amount  of  strain  were  placed  upon  it.  ^Yhile  the  silver 
plates  covering  a  broad  surface  upon  each  side  do  assist  in  this  respect, 
these  sutures,  or  any  other  similar  ones,  do  not  give  absolute  security 
against  tension. 


636    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

The  fact,  however,  that  a  plate  upon  each  side  of  the  palate  makes 
it  unnecessary  for  the  wire  to  cross  the  palate  again,  thus  leaving  the 
tissue  free,  reduces  the  danger  of  cutting  out  very  considerably,  and 
does  not  interfere  with  circulation,  as  it  otherwise  might  (Figs.  486,  487 
and  488). 


Fig.  487. — Fissure  borders  coapted  with  pyoktanin  gut  and  horse-hair  sutures.    Tension 
suture  in  place  and  the  last  shot  being  compressed  to  hold  the  plates. 


The  sutures,  as  the  author  inserts  them,  are  a  modification  of 
those  used  by  Dr.  Fillebrown,  who  first  called  his  attention  to  the  use 
of  the  silver  plates.  The  change  that  has  been  made  is  in  the  use  of 
perforated  lead  shot,  which  are  slipped  over  the  wires  and  pinched 
down  upon  the  plate  (Fig.  487) .  By  using  a  series  of  four  of  these,  they 
can  be  readjusted  and  tightened  a  little  from  tune  to  time,  as  the 
operation  progresses.  Thus  the  exact  pressure  on  the  retention  plates 
and  the  resistance  they  have  to  overcome  are  easily  and  accurately 
adjusted. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


637 


During  recent  years  the  author  has  used  silkworm  gut  almost 
entirely  instead  of'  wire.  It  has  been  found  to  be  much  more  easily 
handled  than  any  kind  of  wire,  and  is  quite  as  reliable  for  this  purpose 
in  every  way.  It  is  used  with  the  silver  plates,  and  shot  the  same  as 
described  for  the  wire  suture. 


Fig  488  —The  operation  fompleted  and  the  final  clipping  of  tension  causing  fibers 
being  made  to  give  not  only  freedom  from  tension  but  a  broader  palate  surface  for  better 
speech  purposes.  ReUef  incisions  such  as  are  shown  in  this  illustration  are  only  required 
in  comparatively  rare  cases  in  which  the  tissue  is  very  scant. 

Author's  Operation.— The  method  of  operation  is  shown  in  Figs. 
480  to  488.  It  covers  quite  closely  in  a  general  way  what  might  be 
known  as  the  old  method  of  performing  staphylorrhapy,  with  certam 
modifications  which  have  from  time  to  time  been  adopted. 

Separation  of  Mucoperiosteum.— If  in  the  separation  of  the  peri- 
ostium  from  the  bone  surface  the  membrane  of  the  overlying  tissues 
which  form  the  mucoperiosteal  flaps  suffers  undue  traumatic  injury, 
the  danger  of  sloughing  is  very  materially  increased.  In  order  that 
this  mav  be  accomplished  vath  as  little  bruising  or  damage  as  practi- 


0)38 


HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


cable,  the  author  has  had  his  own  periosteal  elevators  made  for  delicate 
manipulation.  These  are  in  different  sizes  and  angles,  with  very 
smooth,  slightly  convex  surfaces  (see  Figs.  491  and  492,  C,  C,  D,  E,  F, 
G,  II,  I).  The  reason  for  this  is  that  palates  not  only  differ  in  size, 
but  also  have  different  angles,  and  even  slight  force  applied  in  a  direc- 
tion which  would  easily  separate  the  periosteum  from  the  bone  in  one 
case  might  bruise,  tear,  or  break  it  with  serious  injury  in  another. 
By  having  the  angle  of  the  instrument  regulated  to  the  slope  of  the 
palate  wall,  this  difRcult>'  is  to  some  extent  obviated  and  more  delicate 
manipulation  made  possible. 


Fig.  489. — The  author's  method  of  palate  operation  for  infants.  The  attachment 
sHpped  through  the  arm  of  the  modified  gag  clasps  the  anterior  part  of  the  ah'eolar 
ridge  as  shown.    The  incisions  as  used  for  these  cases  are  as  described. 


It  is  frequently  necessary  to  cut  the  bands  of  scar  tissue  and 
unusually  resisting  attachments  that  prevent  the  periosteum  from 
being  lifted  easily.  This  difficulty  is  overcome  by  a  set  of  knives  with 
angles  corresponding  to  the  form  of  the  periosteal  ele^'ators,  so  that, 
with  the  elevator  making  tension  upon  the  tissue,  the  knife  can  be 
passed  under  it  (Fig.  482)  with  perfect  safety  and  be  depended  upon 
to  cut  the  resisting  attachment  without  inadvertently  damaging  the 
periosteum  (Fig.  492,  K,  L,  M,  N). 

Needles. — ^The  needles  are  of  different  curves,  shaped  something 
like  a  corkscrew,  so  that  when  passed  in  upon  one  side  it  can  easily  be 


SURGICAL  TREATMEKT  OF  CLEFT  PALATE 


039 


calculated  where  the  point  will  show  upon  the  other  (Figs.  4^)1  and 
492).  With  these  the  author  finds  it  possible  to  work  at  greater 
advantage  than  with  a  needle  holder,  because  his  hand  is  not  in  the 
way  to  obscure  the  line  of  vision. 

Postoperative  Changes  in  Palate  Form. — Observation  of  the  changes 
that  take  place  in  the  form  of  palates,  both  hard  and  soft,  not  only 
during  the  first  few  weeks  immediately  following  closure  of  clefts  by 
operation,  but  during  at  least  several  years  afterward,  brings  to  notice 
a  number  of  facts  that  should  have  a  direct  bearing  upon  operative 
procedures. 


Fig.  490. — The  hard  palate  closed  and  the  tissue  of  soft  palate  brought  close  together 
but  not  sutured  as  advocated  for  infants  when  the  hard  palate  is  cleared  first,  and  the  soft 
palate  one  year  later  as  described  in  the  text. 


The  first  strain  upon  sutures  occurs  at  the  time  of  the  operation, 
when  the  flaps  are  moved  over  to  be  brought  into  contact.  If  properly 
relie\ed  and  the  sutures  securely  placed,  this  quickly  disappears. 
In  natural  order  it  occurs  that  the  healing  of  the  incisions  made  to 
relieve  tension,  and  the  tension  of  the  flaps  which  have  been  brought 
down  from  the  bone  surfaces  caused  by  the  periosteum  seeking  its 
normal  situation,  gives  rise  to  a  tendency  to  pull  apart  in  the  median 
line,  which,  if  unanticipated,  is  very  apt  to  bring  disaster  just  when  the 
sm"geon  is  beginning  to  congratulate  himself  upon  success. 


640    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 


ri  i  Fig.  491.— The  author's  set  of  staphylorrhaphy  instruments:  A,  self-retaimng  ten- 
k i  faculum  forceps  for  holding  the  soft  palate  taut;  B,  retractor;  C,  C,  right  and  left  periosteal 
[j  ";      elevators;  D,  E,  F,  G,  periosteal  elevators;  Q,  wire  cutter;  S,  needles. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE  641 


Fig.  492. — The  author's  set  of  staphylorrhaphy  instruments:  a,  self -retaining  tenac- 
ulum forceps;  H,  I,  periosteal  elevators;  K,  L,  M,  N,  knives  of  different  angles;  0,  P, 
straight  knives;  R,  lead  shot  compressor;  S,  needles  of  different  sizes  and  curves;  T,  hook. 

41 


642 


HARELIP,  CLEFT  PALATE,   AND  DEFECTS  OF  SPEECH 


Many  patients  have  come  to  the  author  with  histories  of  previous 
unsuccessful  attempts  to  have  their  palates  closed.  In  them  the  opera- 
tion appeared  to  be  perfect  for  several  days,  and  then  the  palate 
opened  up  again. 


Fig.  493. — Palate  view  of  typical 
case  of  double  harelip  and  cleft 
palate  showing  the  characteristic 
deformities  of  the  nose  and  palate. 


Fig.  494. — Photi.maph  nf  girl,  showing 
fissure  in  the  velum  palati. 


Fig.  495. — Picture  of  mouth  of  the 
same  patient  as  in  Fig.  494  after  opera- 
tion. 


Fig.  496. — Photograph  of  the  mouth 
of  a  patient  with  cleft  through  both  hard 
and  soft  palates. 


Ten  days  to  two  weeks  is  about  the  time  during  which  retention  must 
usually  be  provided  for,  before  all  sutures  can  safely  be  removed. 

From  this  time  on,  during  several  months,  there  is  a  gradual  rounding 
of  the  palate  surface,  the  arch  becoming  higher  and  the  pillars  of  the 
fauces  more  directly  outlined.  Future  form  of  the  palate  depends 
upon  natural  growth  as  influenced  by  respiration  and  its  use  in 
speech. 


SURGICAL  TREATMENT  OF  CLEFT  PALATE 


CAS 


In  nearly  all  cases  the  velum  has  much  the  same  appearance  after 
operation,  but  some  of  the  author's  patients  who  have  made  more  than 


Fig.  497. — Same  patient  as  in  Fig.  496,  with  the  appUance  used  for  reduction  of  the  bone 

deformity  in  place. 


Fig.  498. — Photograph  after  fissures  through  both  hard  and  soft  palates  have   been 

completely  closed. 

ordinary  speech  or  vocal  effort,  and  who  have  made  the  greatest  strides 
toward  speech  improvement,  have  had  their  soft  palates  become  lined 


644    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

and  creased  by  developing  muscles,  and  have  lost  much  of  the  smoothly 
outlined  surfaces  that  were  observed  a  few  weeks  after  closure. 

Among  these  patients,  with  ages  varying  from  fourteen  to  fifty  years 
at  the  time  of  operation,  are  a  number  who  show  almost  no  speech 
defect  that  would  be  noticed  in  ordinary  conversation,  especially  among 
strangers,  as  an  indication  of  cleft  palate,  yet  the  appearance  of  their 
palates  would  be  disappointing  if  compared  with  others  in  whom  the 
speech  results  are  not  as  good. 

The  cause  of  this  is  that  great  effort  is  required  to  coerce  the  newly 
adjusted  and  but  partly  developed  palate  muscles  to  perform  their  parts 
in  speech  ofEce,  and  unusual  development  is  the  natural  result. 

Muscular  Aligcn^ent. — The  lesson  to  us  as  influencing  operative 
methods  is  to  emphasize  the  necessity  of  perfect  alignment  with  the 
uvula  in  the  center,  in  order  that  the  detached  muscles  at  each  side 
may  form  as  perfectly  outlined  arches  as  possible,  that  the  back  of  the 
tongue  may  find,  as  nearly  as  may  be,  the  natural  outline  when  it 
meets  the  posterior  border  of  the  palate,  and  the  postnasal  space  be 
closed  as  readily  as  conditions  will  allow,  and  all  muscles  of  the  palatal 
region  coordinate  with  at  least  reasonable  perfection.  Figs.  493  to 
498  are  examples  of  different  forms  of  palate  fissures  and  the  results 
of  operations  performed  by  the  author  according  to  the  methods  here 
described. 


SPEECH  RESULTS  OF  CLEFT  PALATE  OPERATION. 

In  consideration  of  what  may  safely  be  promised  to  those  who 
contemplate  surgical  operation  for  the  closure  of  cleft  palates,  and  the 
more  or  less  complete  correction  of  the  defects  from  which  such  persons 
suffer,  there  are  many  elements  that  must  be  taken  into  account. 

1.  Above  and  beyond  all  else  is  the  individual  feeling  on  the  part  of 
those  aifiicted.  No  normal  person  can  fully  comprehend  this.  None 
can  know  what  this  means  save  those  who  have  reached  sufficient  age 
to  suffer  the  scoffs  and  jibes  of  school  children,  the  heart-trying  struggle 
to  keep  up  in  school  or  college  with  the  handicap  of  imperfect  speech, 
or  the  bitterness  of  social  ostracism,  even  though  largely  self-inflicted 
through  supersensitiveness,  and  the  untold  trials  of  wage  earning  or 
other  battles  of  life  in  competition  with  the  anatomically  perfect 
though  often  less  gifted  mentally. 

2.  More  healthy  conditions  of  nose  and  pharynx  mean,  in  greater  or 
lesser  degree,  better  general  health,  and  particularly  protection  against 
deafness  due  to  the  middle-ear  disease  that  so  commonly  results  from 
unusual  Eustachian  exposure  through  open  palate  fissures. 

3.  No  plates,  obturators,  or  any  sort  of  mechanical  appliance  could 
give  either  of  the  two  foregoing  benefits. 

4.  There  is  the  infinite  satisfaction  of  knowing  that  throughout 
life  continued  speech  improvement  is  possible,  and  that  whatever 
may  be  accomplished  in  this  direction  is  permanent,  not  subject  to 


SPEECH  RESULTS  OF  CLEFT  PALATE  OPERATION 


645 


Fig.  499.  —  Illustration  prepared  to 
represent  as  nearly  as  possible  the  unequal 
division  of  the  soft  palate  which  frequently 
results  from  the  destructive  processes  fol- 
lowing imperfect  early  operations,  and 
which  makes  operative  conditions  much 
more  difficult. 


Fig.  500.  —  Illustration  representing 
the  condition  of  the  mouth  of  a  boy, 
aged  twelve  years.  His  first  operation 
was  performed  in  infancy.  Following 
this  several  other  unsuccessful  opera- 
tions were  made  in  attempt  to  close  the 
palate  fissure  before  he  came  under  the 
author's  care.  The  unequal  muscular 
activity  had  been  militating  against 
success.  This  fibrous  band  of  tissue  was 
freed  with  the  underlying  periosteum 
and  muscular  readjustment  accomplished 
when  these  openings  were  closed.  The 
result  is  that  at  his  present  age,  seventeen, 
this  young  man  can  speak  almost  with- 
out speech  defect. 


Fig.  501. — Cast  of  the  mouth  of  a  child, 
showing  the  contraction  and  loss  of  teeth 
from  a  compression  in  early  infancy  opera- 
tion and  the  loss  of  tissue  which  makes 
closure  exceedingly  difficult. 


Fig.  502. — Draiving  from  the  cast  of 
the  mouth  of  a  young  woman,  aged 
twenty-eight  years.  Palate  was  closed 
by  compression  in  early  infancy.  Her 
upper  dental  arch  is  so  narrow  and  the 
palate  so  high  that  the  freedom  of  the 
tongue  in  speech  is  so  inhibited  as  to 
make  good  speech  sounds  practically 
impossible.  She  has  also  a  correspond- 
ing contraction  of  the  nares  with  marked 
deflection  of  the  septum. 


646    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

uncertainties  of  accidental  loss  or  breakage,  or  change  in  perfection 
of  adjustment  through  absorption  or  growth  of  surrounding  structures, 
with  attendant  difficulties  of  reconstruction;  and  necessity  of  again 
becoming  accustomed  to  the  new  or  altered  appliance.  All  this  must 
in  the  natural  course  be  expected  with  artificial  appliances,  to  say 
nothing  of  the  cleanliness  of  natural  tissue  as  compared  with  unclean- 
liness  of  plates  under  these  conditions. 

5.  There  is  some  degree  of  immediate  improvement  in  speech,  for 
almost  invariably  speech  becomes  easier  and  is  effected  with  less 
eftort;  but  beyond  this,  progress  is  dependent  upon  a  number  of 
modifying  factors. 

Conditions  which  Govern  Speech  Progress  after  Operation. — Post- 
operative results  show  that,  although  there  is  always  more  or  less 
noticeable  defect  present  in  speech  sound,  some  patients  gain  marked 
improvement  almost  immediately,  and  this  with  comparatively  little 
conscious  effort  or  speech  training.  In  other  cases  voice  change  for 
the  better  is  exceedingly  slow  and  can  be  acquired  only  after  long  and 
patient  effort.  In  considering  the  different  factors  that  must  neces- 
sarily play  a  part  in  this  condition  of  results,  one  element  of  purely 
etiological  character  is  of  primary  importance. 

The  Influence  of  Etiological  Factors. — As  previously  stated,  it  is 
the  author's  custom  wherever  practicable  to  trace  as  accurately  as 
possible  the  family  history  of  each  patient  through  at  least  three 
generations.  In  approximately  10  per  cent,  a  history  of  direct  heredity 
in  the  family  appeared,  and  upon  one  side  or  the  other  ancestors 
affected  by  either  harelip  or  cleft  palate  or  both  were  found.  The 
number  in  which  maternal  impressions  play  a  part  is  so  small  as  to  be 
of  little  significance.  Many  of  the  stories  told  by  mothers  and  rela- 
tives of  shock,  fright,  or  other  maternal  impressions  during  pregnancy 
when  analyzed,  are  found  to  have  occurred  too  late.  Little  thought  is 
commonly  given  to  these  matters  earlier  than  the  fifth,  seventh,  or 
eighth  week,  and  it  is  during  this  period  only  that  this  factor  would 
be  of  etiological  importance.  Careful  study  of  the  family  histories, 
however,  quite  often  reveals  the  fact  that  relatives  have  been  subject 
to  mental  peculiarities,  nervous  affections,  diseases  of  the  heart, 
aneurysm,  tuberculosis,  cancer,  or  paralysis.  These  and  other  affec- 
tions occur  with  astonishing  regularity.  Usually  there  is  compara- 
tively little  difficulty  in  tracing  upon  either  the  paternal  or  maternal 
side,  and  sometimes  both,  these  evidences  of  an  unstable  nervous 
system  and  irregular  or  insufficient  bodily  or  mental  development 
which  indicate  arrest  of  development  during  the  early  embryonic 
period. 

The  bearing  of  this  upon  the  subject  is  chiefly  made  apparent  by  an 
important  fact  which  the  author  has  been  unable  to  find  noted  by 
other  writers,  but  which  he  has  so  frequently  met  in  dealing  with  these 
cases  as  to  warrant  mention. 

By  no  means  invariably,  but  quite  frequenth%  he  has  noticed  that 


SPEECH  RESULTS  OF  CLEFT  PALATE  OPERATION         647 

either  the  father  or  the  mother  of  a  cleft-palate  patient  had  some 
peculiarity  of  speech.  In  none  of  these  cases  has  the  peculiarity  been 
noticed  or  associated  in  any  way  with  cleft  palate,  and  though  he 
has  been  unable  to  examine  all  cases,  it  is  fair  to  assume  that  in  the 
outward  appearance  of  the  palate  there  was  no  defect.  Nevertheless, 
careful  attention  has  demonstrated  that  there  was  unquestionably, 
in  greater  or  lesser  degree,  tendency  to  nasal  or  imperfect  speech 
sounds  such  as  are  more  markedly  noticeable  with  cleft-palate  patients. 
It  would  seem,  then,  that  there  must  be  in  these  individuals  either  a 
nervous  inefficiency  in  the  speech  mechanism  or  a  slight  imperfection 
of  anatomical  development,  either  of  which  in  the  next  generation  has 
become  exaggerated  into  complete  fissure  and  consequent  speech 
difficulty. 

Many  persons  whose  palates  are  only  slightly  imperfect,  the  uvula 
being  bifid  and  both  velum  and  hard  palate  apparently  complete,  have 
marked  speech  defects.  These  cases  are  more  specifically  described 
under  the  heading  of  Speech  Defects  without  Cleft  Palate. 

Significance  of  Corrective  Influences  in  Embryo. — ^That  Nature  does 
repair  both  harelip  and  cleft  palate  in  embryo  is  quite  frequently 
demonstrated  by  individuals  who  have  a  mark  extending  the  full 
length  of  the  lip  with  notch  at  the  labial  border.  Such  lips  have  the 
appearance  of  having  been  imperfectly  operated  upon  in  early  infancy, 
although  no  such  operation  has  been  performed,  because  the  lip  was 
in  this  condition  at  birth. 

Speech  Defects  Directly  Due  to  Postoperative  Imperfections. — 
Observation  of  cases  after  operation,  and  particularly  those  in  which, 
on  account  of  imperfect  operative  methods,  there  has  been  little  or  no 
improvement,  speech  progress  under  training  being  slow,  leads  to  the 
following  conclusions  in  explanation  of  these  difficulties  in  many 
instances. 

Ill-advised  Operations  in  Early  Infancy. — Where  forcible  means  have 
been  employed  in  early  infancy  to  bring  the  sides  of  the  fissure  into 
direct  or  too  close  approximation,  the  arrested  development  of  the 
maxillary  bones  makes  the  anterior  portion  of  the  mouth  too  small  for 
accomodation  of  the  tongue  in  the  utterance  of  word  sounds.  This 
disadvantage  is  increased  by  the  fact  of  the  early  disarrangement  of 
developing  germs  of  teeth  through  forcible  compression  of  the  parts. 
Not  only  are  the  incisors,  cuspids,  and  bicuspids  erupted  in  such 
position  as  to  reduce  the  size  of  the  dental  arch,  but  frequently  one  or 
more  teeth  erupt  almost  in  the  central  portion  of  the  palate. 

Under  these  conditions,  words  beginning  with  c,  d,  g,  h,  j,  k,  I,  n,  r,  s, 
t,  X,  z,  all  of  which  the  tongue  utters  principally  behind  the  teeth  and 
with  little  or  no  assistance  from  the  lips,  are  exceedingly  difficult,  if  not 
practically  impossible,  to  utter  correctly. 

Disarrangement  of  the  anterior  teeth,  since  the  teeth  are  more  or  less 
involved  in  pronunciation  of  all  letters,  widens  the  range  of  defective 
sounds  materially.     Where  any  portion  of  the  protruding  premaxilla 


648        HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

has  been  removed  for  the  purpose  of  faciUtating  lip  closure  in  infancy 
the  non-eruption  of  teeth  in  this  region  is  also  a  very  serious  disad- 
vantage. 

Scars  that  stiffen  and  distort  the  lip,  and  which  are  so  commonly 
noticeable  on  account  of  improper  operative  treatment  in  infancy, 
affect  all  words  beginning  with  b,  f,  m,  p,  v,  w. 

Maldevelopment  of  Nasal  and  Other  Parts  Accessory  to  Speech. — 
Imperfections  from  wrong  methods  of  early  treatment,  such  as  noses 
that  have  the  characteristic  appearance  of  leaning  to  one  side,  with 
the  cartilaginous  wing  more  or  less  flattened,  usually  have  deflection 
of  the  septum  with  tendency  to  unequal  develo})ment  amounting 
to  partial  stenosis  upon  one  or  both  sides,  or  one  naris  may  be  unusually 
large  with  corresponding  enlargement  of  the  turbinal  bodies.  Hyper- 
trophy of  the  nasal  mucous  membrane  and  other  pathological  condi- 
tions that  are  in  natural  sequence  to  these  conditions  tend  to  nasal 
speech  sounds  even  in  persons  otherwise  normal,  and  are  obviously 
disadvantageous  when  other  speech  difficulties  incident  to  cleft  palate 
speech  habits  act  as  a  still  greater  complication. 

Hard  Palate  too  Short  and  too  Flexible. — Shortening  of  the  hard 
palate  in  its  anteroposterior  measurement,  such  as  often  occurs  from 
WTong  operative  methods  and  failure  to  develop  cartilaginous  or  bony 
tissue  of  sufficient  firmness  to  act  as  a  sounding  board,  or  to  give  the 
degree  of  stiffness  required  for  proper  muscular  action  from  points  of 
attachment  thereto,  is  a  matter  of  much  importance,  since  physio- 
logical action  of  the  muscles  of  the  soft  palate  depends  upon  the  outline 
and  character  of  the  posterior  border  of  the  hard  palate.  Methods  of 
operation  by  which  the  periosteum  is  carried  over  accurately  and  with 
as  little  injury  as  possible,  to  be  united  in  the  central  palatal  line, 
are  advisable  because  they  favor  formation  of  bone.  Conversely, 
methods  by  which  flaps  are  turned  over  and  the  relation  of  the  periosteal 
and  mucous  membrane  surfaces  is  altered,  while  they  may  be  success- 
ful in  closing  the  palate  fissure,  are  ill-advised  because  a  membranous 
yielding  tissue  covering  the  region  of  the  hard  palate  cannot  give  as 
good  speech  results  as  one  more  firmly  resistant  may  be  expected 
to  produce. 

Velum  Insufficient  through  Abnormal  Hard  Palate  Borders,  Scars,  etc. — 
On  account  of  ill-formed  hard  palate  at  the  posterior  border,  or  because 
of  its  own  insufficiency,  the  velum  palati,  after  being  closed  by  opera- 
tion, is  sometimes  too  short,  drawn  too  tightly,  or  too  stiffened  by 
scars  to  enable  it  to  be  made  to  approach  the  pharyngeal  wall,  or  meet 
the  base  of  the  tongue  with  sufficient  readiness  properly  to  perform  its 
speech  function  in  governing  escape  of  air  through  nose  and  mouth  in 
sound  making. 

Possibilities  of  Improvement  of  These  Cases. — A  study  of  the 
principal  difficulties  that  stand  in  the  way  of  speech  improvement  for 
those  who  have  had  cleft  palates  closed  by  operation  leads  naturally 
to  the  conclusion  that  corrective  treatment  must  be  along  two  distinct 


SPEECH  RESULTS  OF  CLEFT  PALATE  OPERATION         649 

lines.  The  author's  experience  has  shown  that  almost  incalculable 
assistance  may  be  given  such  patients  by  (1)  improved  operative 
methods,  and  (2)  better  speech  training. 

The  lesson  to  be  read  from  the  unfortunate  results  of  imperfect 
or  ill-advised  treatment,  as  evidenced  in  results  of  operation  upon 
this  unfortunate  class  of  patients,  is  not  alone  that  exceedingly  great 
care  should  be  exercised  in  order  that  no  unnecessary  violation  of 
natural  processes  of  development  in  early  infancy  or  later  develop- 
mental periods  should  be  allowed,  but  also  that  through  operative 
means  much  may  be  accomplished  by  an  efl'ort  to  undo  the  damage 
that  has  been  done  by  reconstruction,  readjustment,  and  improvement 
of  the  malformed  parts  by  surgical  operation. 

Reconstruction  of  Deformed  Lips. — Because  of  reconstruction  of 
the  lip  which  is  ofter  too  long,  or  scar  contraction  upon  the  inside, 
the  lip  has  a  tendency  to  curve  inward  instead  of  having  the  natural 
outward  roll.  It  may  also  be  that  the  lip  is  too  short  or  distorted 
through  wrong  muscular  attachment.  These,  as  well  as  other  lip 
deformities,  can  be  much  improved  and  the  lip  made  more  useful  for 
labial  speech  office  (see  Figs.  443  to  463,  pp.  613  to  618). 

In  many  instances,  through  destruction  or  injiu-y  to  the  premaxilla, 
there  is  no  development  of  the  dental  arch  anterior  to  the  cuspid  teeth, 
or,  if  the  incisors  be  erupted  at  all,  they  are  in  such  form  as  to  be  of 
little  practical  assistance  in  restoring  the  contour  of  the  face  and  giving 
necessary  labial  support  as  well  as  speech  assistance  in  the  utterance 
of  dental  sounds. 

Correction  of  Deformity  of  the  Dental  Arch. — The  dental  arch  must 
be  restored  to  its  natural  form  and  relation  to  both  the  lips  and  occlu- 
sion with  the  lower  jaw.  The  simplest,  most  direct,  and  satisfactory 
means  of  accomplishing  this  is  by  the  insertion  of  teeth  arranged  in 
proper  form  and  attached  to  teeth  in  the  jaw  by  means  which  dentists 
fully  understand  and  commonly  practice. 

In  the  next  class  of  cases  the  teeth  are  erupted,  in  malposition, 
with  the  upper  dental  arches  contracted.  These  arches  may  be 
expanded  and  the  teeth  placed  in  proper  relation  so  that  the  tongue 
may  have  sufficient  room  to  give  proper  speech  assistance  while  both 
buccal  and  labial  tissues  are  held  in  better  form.  This  should  only 
be  attempted  with  exceeding  great  care  and  due  control  of  pressure, 
so  that  no  separation  of  the  line  of  palate  union  may  occur  and  unfor- 
tunate reopening  of  the  palate  be  brought  about.  For  this  reason 
methods  usually  employed  in  correction  of  dental  irregularities  must 
be  avoided  or  carefully  modified. 

The  results  of  correction  under  these  conditions  have  been  very 
gratifying  in  large  numbers  of  cases.  In  one  case  recently,  where  the 
velum  after  closure  was  less  flexible  than  seemed  desirable,  through 
the  fact  that  the  patient  was  thirty  years  old  before  the  author  per- 
formed the  operation,  and  though  no  scar  stiffening  interfered  with 
movement,  the  tissue  was  so  scant  through   want  of  development 


650    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

as  to  give  this  result.  A  new  operation  was  performed  by  making 
incisions  upon  each  side  and  carrying  tension  sutures  of  wire  through 
from  one  side  to  the  other  without  in  any  way  interfering  with  the 
central  portion  of  the  palate,  allowing  granulation  to  fill  the  division 
in  the  tissue  thus  made,  and  in  that  way  gaining  additional  freedom 
of  the  soft  palate.     The  speech  results  in  this  case  are  exceedingly  good. 

Correction  of  Defects  by  Operative  Assistance. — The  question  of 
reoperation  in  the  region  of  the  hard  palate,  where  tissue  covering 
fissure  has  remained  too  flexible,  is  one  that  requires  careful  considera- 
tion, for  fear  of  doing  injury  to  what  has  already  been  accomplished  in 
the  closiu"e  of  the  fissure  with  tissue.  Under  favorable  conditions, 
however,  the  mucoperiosteal  flaps  can  be  separated  from  the  bone 
surfaces  and  carried  to  the  center  as  for  the  original  palate  operation, 
thus  gaining  an  increase  of  the  surface  which  best  promises  cartilage  or 
bony  development.  This  operation  the  author  has  usually  performed 
coincidently  with  an  operation  demanded  for  some  other  purpose, 
but  the  results  were  such  as  to  indicate  that  there  is  hope  for  future 
improvement  of  many  otherwise  comparatively  hopeless  cases  from 
this  method  of  treatment. 

Conclusions  from  Phonographic  Speech  Records. — Phonographic 
records  that  the  author  has  taken  of  speech  before  and  after  operation 
in  all  of  the  different  degrees  of  palate  fissure,  as  might  naturally  be 
expected  with  a  large  number  of  cases,  have  demonstrated  some 
curious  facts.  The  cases  ranged  from  a  slight  separation  at  the  pos- 
terior border  of  the  velum  on  through  partial  and  complete  clefts  of 
both  hard  and  soft  palates  varying  in  width  of  the  separation.  Chief 
in  point  of  interest  is  the  evidence  that  sometimes  an  individual  with 
only  a  bifid  uvula,  the  rest  of  the  palate  being  intact  and  apparently 
normally  developed,  will  speak  more  imperfectly  and  with  greater  ex- 
aggeration of  the  nasal  and  other  defective  sounds  common  to  persons 
with  cleft  palates  than  others  whose  fissures  are  much  more  exten- 
sive. Some,  in  fact,  with  complete  fissure  through  both  hard  and  soft 
palates  are  able  to  speak  more  clearly  than  those  with  almost  imper- 
ceptibly defective  ones. 

Many  individuals  with  practically  no  palate  sing  quite  well,  even 
though  unable  to  speak  words  with  sufficient  correctness  to  be  under- 
stood. 

Case  I. — This  was  that  of  a  girl,  aged  fourteen  years,  who  had  only 
a  fissure  in  the  soft  palate  before  operation.  It  was  impossible  to 
distinguish  speech  sounds  sufficiently  for  unaccustomed  persons  to 
understand  what  she  said.  Therefore  a  phonographic  record  would 
have  been  a  mere  jargon  of  unintelligible  sounds.  She  had  been  unable 
to  get  beyond  the  fourth  grade  in  the  public  schools  because  teachers 
could  not  understand  her.  Immediately  after  operation  marked 
improvement  was  noted  by  record.  Later  records  showed  remarkable 
change  for  the  better,  and  on  one  or  two  occasions,  after  training,  she 
has  recited  before  large  audiences,  with  much  clearness  and  a  very  good 


SPEECH  HESULTS  OF  CLEFT  PALATE  OPERATION         651 

approximation  of  perfection  of  sound,  verses  in  which  she  had  been 
drilled,  but  in  general  conversation  her  progress  was  not  in  proportion 
to  that  of  better  educated  patients,  as  was  noted  in  records  of  other 
cases.  Eagerness  in  conversation  always  tended  to  cause  lapses  into 
old  speech  habits,  and  in  this  case  such  difficulty  was  hard  to  overcome; 
a  difference  being  apparent  if  she  were  allowed  to  associate  for  a  time 
with  people  who  themselves  spoke  incorrectly  or  carelessly  or  the 
reverse. 

Case  II. — Another  girl,  aged  twenty-two  years,  with  the  same 
character  of  fissure,  but  who  had  a  high-school  education,  could  speak 
much  better  than  the  preceding  one  before  operation,  the  range  of  her 
mtelligible,  even  though  somewhat  nasal,  sounds  being  much  less 
limited.  After  closure  of  the  cleft,  though  operative  results  were 
quite  perfect  in  both  cases,  her  progress  in  the  line  of  improvement 
in  conversational  sounds  was  shown  by  the  record  to  be  much  more 
marked. 

Case  III. — Patient,  aged  thirty-eight  years,  was  the  mother  of  a 
grown-up  family.  The  cleft  in  soft  palate  was  the  same  as  Cases 
I  and  II.  She  was  not  well  educated,  but  not  ignorant  and  of  less 
nervous  temperament  than  the  other  two.  Speech,  as  might  be 
expected,  was  better  than  Case  I  and  not  so  good  as  Case  II.  Soon 
after  operation,  therefore,  without  training,  her  record  was  found  to  be 
surprisingly  good,  due  in  a  considerable  measure,  no  doubt,  to  freedom 
from  nen'ousness.  Later  reports  of  improvement  were  much  more 
favorable  than  was  expected. 

Case  IV. — This  patient,  a  girl,  aged  sixteen  years,  in  whom  the 
fissure  was  confined  to  the  velum,  as  in  all  the  preceding  cases,  was  as 
uneducated  as  the  first  patient,  but  with  less  natural  intelligence. 
Scarcely  a  single  word  in  her  first  record  could  be  understood.  Later  and 
after  much  training  she  was  able  to  recite  simple  rh\Tnes  before  large 
audiences  quite  well,  but  she  has  never  acquired  good  speech.  Not- 
withstanding this  deficiency,  she  can  repeat  after  another  person, 
sentence  by  sentence,  even  most  diflScult  combinations  of  words,  with 
little  noticeable  speech  defect. 

Case  V. — A  girl,  aged  twenty-two  years,  who  had  an  acquired  fissure 
of  the  velum,  due  to  hereditary  s}T)hilis,  was  operated  on  after  pre- 
paratory administration  of  potassium  iodide,  with  successful  results 
so  far  as  closing  the  opening  was  concerned.  It  was  not  perfect  in 
the  sense  that  the  preceding  cases  were,  because  cicatricial  contrac- 
tions, due  to  previous  ulcerative  processes,  had  stiffened  the  tissue. 
Notwithstanding  the  fact  that  this  deformity  was  acquired  at  about 
the  age  of  fourteen  years,  and  the  patient's  education  was  above  the 
average,  there  was  less  improvement  after  operation  than  in  any  of  the 
other  cases. 

Case  VI. — In  contradistinction  to  these  other  cases,  a  little  boy, 
aged  nine  years,  whose  congenital  cleft  in  the  velum  was  like  that 
in  Case  V,  with  \ery  imperfect  speech,  was  able  to  improve  so  rapidly 


652    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

that  between  the  months  of  May  and  November  defects  were  so  over- 
come that  his  school-teacher  did  not  notice  unusual  difference  from 
other  children  of  the  same  age. 

Case  VII. — A  girl,  aged  twenty-two  years,  fairly  well  educated, 
with  opening  in  velum  palati  alone,  in  whom  speech  sounds  were  very 
bad  before  operation,  was  able,  by  reason  of  good  ear  and  singing 
practice,  to  improve  sufficiently  to  be  able  to  pray  and  sing  alone  at 
Salvation  Army  meetings  within  a  few  months  from  time  of  closure. 
In  this  case,  undoubtedly,  religious  zeal  helped  to  overcome  self- 
consciousness,  together  with  other  mental  and  nervous  hindrances, 
while  constant  attendance  on  the  meetings  of  the  Army  gave  the  best 
possible  training  to  the  vocal  apparatus. 

Case  VIII. — A  young  man,  aged  eighteen  years,  had  a  complete 
cleft  of  both  hard  and  soft  palates.  He  is  a  graduate  of  a  high  school. 
Before  operation  he  was  almost  impossible  to  understand,  yet  in  repeat- 
ing the  alphabet  unusual  ability  to  pronounce  each  letter  was  noted, 
even  the  g,  k,  and  c  being  more  than  ordinarily  good.  Stammering 
was  the  prime  cause  of  his  speech  difficulty.  The  record,  taken  two 
days  after  the  last  stitches  were  removed,  complete  union  by  first 
intention  having  taken  place  throughout,  even  to  the  tip  of  the  uvula, 
showed  an  almost  astonishing  result,  since  his  voice  from  the  grapho- 
phone,  singing  the  "Holy  City,"  sounded  better,  perhaps,  than  many 
of  our  own  would  if  a  similar  record  were  taken. 

Case  IX. — A  young  man,  aged  nineteen  years,  with  a  fair  education, 
had  fissure  through  both  hard  and  soft  palates.  The  first  speech 
record  was  better  than  Case  VIII,  on  account  of  freedom  from  nervous 
habit,  but  ability  to  make  separate  sounds  was  less  perfect.  He  could 
sing  "Rock  of  Ages"  quite  well,  and  showed  great  speech  improvement 
in  later  records  as  a  result  of  two  weeks'  singing  and  drill  exercise. 

Case  X. — A  boy,  aged  nine  years,  for  whom  only  the  preparatory 
operation  had  been  performed,  has  gi^'en  two  interesting  records.  In 
one  he  recites  the  "Lord's  Prayer"  with  an  obturator  in  his  mouth, 
and  the  next  equally  well  without  it,  yet  with  cleft  through  both  hard 
and  soft  palates.  It  must  be  understood  that  he  could  not  have 
learned  to  speak  so  well  had  he  not  had  the  mechanical  assistance 
in  the  beginning. 

Case  XI. — ^A  girl,  aged  twenty-two  years,  highly  educated,  but  with 
wide  cleft  through  both  hard  and  soft  palates,  made  worse  by  having 
had  several  previous  unsuccessful  operations,  improved  so  rapidly  after 
the  normal  form  of  the  palate  had  been  restored  by  operation  that  she 
successfully  passed  an  examination  to  teach  in  an  eastern  law  school. 
The  fact  that  she  afterward  filled  an  important  position  and  transacted 
the  telephone  business  of  a  large  establishment  is  sufficient  proof  of  her 
improvement.  Undoubtedly  her  rare  intelligence  and  persistence  have 
been  assisting  factors. 

Hundreds  of  similar  examples  of  clinical  results  confirm  the  correct- 
ness of  the  findings  of  these  phonographic  records. 


SPEECH  DEFECTS  WITHOUT  CLEFT  PALATE  653 

SPEECH  DEFECTS  DUE  TO  IMPERFECT  DEVELOPMENT 
WITHOUT  CLEFT  PALATE. 

Speech  is  an  index  of  individual  sex,  character,  mental  capacity, 
training,  state  of  mind,  nervous  conditions,  general  bodily  health, 
and  past  or  present  developmental  influences. 

Etiology. — The  causes  of  defective  speech,  according  to  Cohn,  are 
stammering,  stuttering,  nasal  defects  or  malformations  of  hard  and 
soft  palates,  deaf-mutism,  and  defects  of  speech  due  to  diseases  of  the 
central  nervous  system. 

Ballenger's  enumeration  of  causes  is  as  follows:  nasal  origin,  epi- 
pharyngeal and  faucial  origin,  lingual  origin,  laryngeal  origin,  thoracic 
and  abdominal  origin,  deaf-mutism,  malformations  of  palates,  and 
central  origin. 

From  the  foregoing  classifications  the  causes  of  defective  speech 
may  be  grouped  with  advantage  to  the  oral  surgeon  into  nervous, 
anatomical ,  and  mechanical  inflvences.  Radical  divisions  of  this  char- 
acter, which  will  readily  be  understood,  cannot  be  arbitrarily  insisted 
upon,  because  factors  belonging  to  each  one  of  these  classes  are  insepar- 
ably dependent  upon  and  associated  wdth  those  that  might  be  classed 
in  another  division.  Congenital  absence  of  the  sense  of  hearing  or 
defective  brain  development  or  nervous  affections  common  to  defectives, 
insofar  as  they  may  prevent  or  militate  against  speech,  are  for  the 
greater  part  beyond  any  surgical  or  medical  control.  Certainly  their 
control  lies  outside  the  field  of  oral  surgery. 

A  considerable  number  of  nervous  affections  are,  however,  susceptible 
to  improvement  by  the  treatment  of  buccal  conditions,  as  may  be 
noted  by  reference  to  the  chapter  on  Nervous  Diseases. 

All  of  the  methods  suggested  in  this  connection  should  be  employed 
when  indicated  to  assist  such  individuals  toward  the  establishment  of 
more  stable  nervous  conditions,  and  to  aid  speech  improvement. 

In  undertaking  the  treatment  of  these  cases  the  most  difficult  feature 
often  rests  upon  the  decision  as  to  w^hether  the  condition  is  susceptible 
of  improvement  or  is  due  to  causes  that  cannot  be  corrected. 

The  Correction  of  Anatomical  Defects. — This  has  already  been 
provided  for  in  the  description  of  the  prevention  and  correction  of 
nasal,  palatal,  lingual,  maxillary,  and  other  oral  malformations;  with 
the  single  exception  of  the  operative  treatment  of  cases  having  defec- 
tive speech  from  imperfectly  developed  palates  that  are  not  cleft,  and 
which  upon  casual  examination  give  no  evidence  of  the  imperfection. 
These  palates  have  been  from  time  to  time  referred  to  in  the  discussion 
of  other  divisions  of  the  subject. 

The  author's  method  of  treatment  is  based  upon  the  belief  that 
when  there  is  no  nerve  lesion  or  congenital  motor  insufficiency  in  the 
control  of  the  movements  of  the  soft  palate,  the  reason  why  there  is 
wrong  escape  of  air  through  the  nose,  with  an  imperfect  sound  such  as 
that  which  is  characteristic  of  cleft  palate  cases,  is  because  it  is  impos- 


654    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

sible  for  such  patients  perfectly  to  approximate  the  posterior  wall  of  the 
pharynx  and  the  soft  palate  at  the  proper  moment,  as  is  shovm  in  Fig. 


Fig.  503 


Fig.  504 


503,  which  illustrates  the  contact  of  the  velmn  with  the  projection  in 
the  pharynx  formed  by  the  pharyngoconstrictor  muscles  whereby 


SPEECH  DEFECTS  WITHOUT  CLEFT  PALATE  655 

closure  of  the  nasal  openings  takes  place.  This  occurs  with  slight 
variations  in  the  pronunciation  of  the  elementary  vowel  sounds  and 
the  consonants  j),  b,  t,  d,  v,  s,  z,  c,  h,  j,  th,  r,  sh,  I.  Fig.  504  shows  the 
impact  of  the  tongue  against  the  soft  palate  required  in  k,  g,  and  ?/f/.^ 
Kingsley's  palatograms  (Fig.  505)  indicate  the  points  of  contact  of  the 
tongue  and  palate  in  articulation  of  speech  sounds. 


^      ^    ^^     zj: 


Fig.  505.— Kingsley's  palatograms.     Show  tongue  and  palate  contact  in  vocalization 

of  letters  indicated. 

Obviously,  if  the  hard  palate  is  short,  the  levator  and  tensor  palati 
muscles  will  not  have  the  same  leverage  as  would  be  the  case  with  a 
perfect  outline  at  the  posterior  border  of  the  hard  palate.  Moreover, 
the  angle  at  which  the  velum  is  suspended  will  be  such  as  to  make  it 
necessary  for  it  to  be  carried  farther  upward  and  backward  in  order 
to  complete  physiological  speech  function  in  relation  to  the  pharyngeal 
wall. 

More  is  therefore  required  of  muscular  action  that  is  necessarily 
deficient.  The  difficulty  is  still  further  increased  because  the  natural 
effect  of  this  condition  upon  the  palatoglossi  muscles  is  to  cause  them 
to  be  shorter  than  w^ould  be  expected  if  their  antagonists  of  the  velum 
were  operating  from  points  of  attachment  farther  back,  as  would  be 
the  case  with  a  normal  hard  palate.    . 

When  the  soft  palate  is  unusually  short,  either  because  of  its  own 
incomplete  development  or  because  of  the  shortness  of  the  hard 
palate,  the  difficulties  of  proper  contact  with  the  base  of  the  tongue 
and  also  with  the  pharyngeal  wall  are  increased.  For  cases  in  which 
the  uncontrollable  conditions  previously  referred  to  have  been  com- 
pletely and  sometimes  partially  excluded  by  diagnosis  the  author  has 
undertaken  to  remedy  the  condition  of  the  velum  by  operation. 

'  American  System  of  Dentistry, 


656         HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

Incisions  are  made  as  shown  in  Figs.  486  and  488  upon  each  side 
of  the  vehmi  in  line  with  the  molar  teeth.  The  tissues  are  separated 
with  the  fingers  and  a  retention  suture  inserted,  as  shown  in  Fig.  486 
for  staphylorrhaphy.  This  suture  is  allowed  to  remain  until  the  heal- 
ing process  has  taken  place  in  such  a  manner  as  to  insure  an  increase 
of  palate  tissue  in  this  region.  By  this  method  greater  freedom  may 
be  given  the  soft  palate  in  its  central  portion,  and  a  certain  amount  of 
rigidity  upon  each  side,  which  is  believed  to  be  beneficial  in  assisting 
function  under  these  conditions. 

Di^'ision  of  the  palatoglossi  muscles,  as  described  for  cases  of  cleft 
palate  and  shown  in  Fig.  485,  when  the  suture  is  inserted,  also  gives 
a  measure  of  freedom  in  this  direction. 

In  some  cases  the  author  has  found  it  necessary  to  draw  together 
tissues  from  the  ends  of  the  transverse  sutures  and  close  them  with 
fine  catgut  sutures  in  a  vertical  line,  thus  preserving  the  increased 
length  of  these  muscles  permanently.  The  operation  which  naturally 
suggests  itself  of  causing  an  increased  bone  development  at  the  pos- 
terior border  of  the  hard  palate  by  raising  the  mucoperiosteum  and 
carrying  it  over  to  a  point  which  will  allow  the  periosteal  borders  to 
meet  in  the  center,  and  retention  in  this  position  by  sutures,  as  in 
closing  cleft  palate,  might  be  warranted  in  some  cases.  Except  under 
unusual  circiunstances,  the  danger,  however,  of  creating  palatal  defects 
whichmight  result  disadvantageously  rather  than  the  reverse  is  too  great. 

The  number  of  cases  operated  upon  by  the  author  as  described 
has  been  limited,  and  the  result  of  speech  training  which  must  neces- 
sarily be  depended  upon  to  supplement  the  anatomical  correction 
have  been  undertaken  too  recently  to  permit  positive  statements  as 
to  the  degree  of  benefit  given. 

Sometimes  a  marked  improvement  immediately  following  the 
operation  is  noted.  At  other  times  the  change  for  the  better  is  less 
apparent,  and  the  progress  of  speech  training  is  such  that  it  is  impos- 
sible to  say  if  progress  is  more  rapid  because  of  the  operation  than  might 
otherwise  be  expected.  Personally  the  author  has  no  doubt  of  the 
necessity  of  surgical  assistance  in  such  cases  the  same  as  with  other 
forms  of  palatal  defects. 

Simple  Methods  of  Speech  Training  Best. — In  the  matter  of  speech 
training,  simplicity  of  method  is  extremely  desirable.  Due  recognition 
must  be  given  to  all  factors  incident  to  indi\'idual  adaptability  and 
talent,  to  which  attention  has  been  called  in  earlier  descriptions  of 
conclusions  drawn  by  the  author  from  phonographic  records  of  patients, 
w^hich  mark  the  tendency  in  this  as  in  any  other  education  to  slow  or 
rapid  progress. 

After  an  experience  of  many  years,  during  which  there  has  been 
unusual  opportunity  to  observe  the  results  of  speech  training  under 
widely  different  conditions,  the  author  feels  called  upon  to  urge  most 
strongly  the  avoidance  of  all  methods  of  instruction  that  are  unneces- 
sarily technical  or  complicated.     They  may  be  alluring  from  the 


SPEECH  DEFECTS  WITHOUT  CLEFT  PALATE  657 

theoretical  standpoint  of  i  more  or  less  limited  observation  of  certain 
aspects  of  this  many-sided  question,  but  it  is  certain  that  the  easier 
and  more  naturally  the  directions  given  to  such  persons  may  be  fol- 
lowed, the  earlier  will  improvement  be  noticed. 

As  an  example  of  this,  two  cases,  both  boys,  aged  about  fourteen 
years,  may  be  cited.  Each  had  had  his  palate  closed  in  infancy,  both 
suffered  in  almost  the  same  degree,  from  contraction  and  ill-develop- 
ment of  both  hard  and  soft  palates,  with  eruption  of  the  teeth  well 
in  toward  the  central  portion  of  the  palate.  With  both  the  author 
used  successfully  the  same  method  of  correction  by  gradual  expansion 
and  reshaping  of  the  palates  and  dental  arches.  One  of  these  had  had 
constant  instruction  from  his  earliest  days  not  only  in  English,  but  also 
in  French,  the  latter  with  a  view  of  assisting  him  in  English,  as  the  learn- 
ing of  foreign  languages  for  such  patients  is  one  of  the  accepted  forms 
of  favoring  speech  improvement.  The  other  little  patient  had  had 
practically  no  training  at  all.  His  parents  wisely  considered  that  unless 
the  anatomical  defects  from  which  he  suffered  could  be  corrected,  it 
were  better  that  he  be  saved  the  trials  of  comparatively  useless  effort 
to  improve.  As  might  have  been  expected,  the  boy  who  had  been 
taught  French  and  who  could  not  make  English  sounds  correctly  was 
unable  to  do  any  better  in  French.  Therefore  he  had  acquired  wrong 
speech  habits  in  two  languages  instead  of  one.  This  is  the  point  that 
should  be  borne  in  mind  by  others  who  may  feel  inclined  to  undertake 
this  means  of  improvement.  The  wonderfully  complicated  studies  of 
consonant  sounds  upon  which  he  had  apparently  spent  many  hours 
that  could  have  been  more  beneficially  employed  out  of  doors,  gaining 
health  and  strength,  only  tended  to  confuse  his  mind  and  lessen  the 
quickness  of  response  of  the  many  elements  of  speech  mechanism. 
The  difference  was  markedly  apparent  because  the  boy  without  pre- 
vious training  made  much  more  rapid  progress  as  soon  as  conditions 
were  favorable,  while  the  other,  though  quite  equal  in  general  intelli- 
gence, was  found  to  be  exceedingly  slow,  and  effort  toward  improve- 
ment was  very  difficult. 

General  Principles. — Better  understanding  of  these  differences 
depends  upon  due  appreciation  of  the  general  principles  which  have 
been  so  well  explained  by  Scripture  in  the  following  manner: 

1 .  Reflex  Tonus. — Tonus  is  a  faint  muscular  contraction  due  to  con- 
tinuous weak  nerve  stimulations,  easily  subject  to  fatigue,  ill  health, 
and  other  demoralizing  conditions,  lack  of  or  disarrangement  of  which 
causes  marked  change  of  voice  in  both  speaking  and  singing. 

2.  Force  of  Movement. — This  depends  on  the  amount  of  stimulus 
sent  to  muscles,  movements  of  which  includes  not  only  those  directly 
involved,  but  also  their  antagonists.  This  requires  an  excess  of  effort 
over  what  might  be  expected,  but  when  the  innervations  are  properly 
coordinated  this  excess  is  not  necessarily  large  and  fatiguing. 

3.  Accuracy  of  Movement.^ — Inaccuracy  of  movement  is  a  funda- 
mental source  of  inaccurate  and  wrong  sounds. 

42 


G58    HARELIP,  CLEFT  PALATE,  AND  DEFECTS  OF  SPEECH 

4.  Precision  of  Movement. — This  refers  to  regularity  and  evenness 
of  execution  and  depends  on  nervous  control. 

5.  Accuracy  and  Precision  of  Coordination.— This  represents  the  ner- 
vous control  over  simultaneous  muscular  movements.  Some  forms 
of  thick  speech  of  alcoholic  intoxication  and  incorrect  adjustments 
during  excitement  are  caused  by  defective  coordination  in  speech  effort. 

6.  Quickness  of  Response. — This  is  action  of  the  nervous  centers 
that  tends  to  become  automatic.  One  object  in  vocal  training  should 
be  to  render  speech  and  song  automatic. 

7.  Quickness  of  Muscular  Movement. — This  depends  on  both  mus- 
cular and  nervous  quickness,  and  must  be  properly  balanced;  other- 
wise speech  appears  labored  or  slurred. 

8.  Auditory  Motor  Control. — The  learning  of  speech  sounds  consists 
largely  in  forming  connections  between  motor  and  auditory  sensations. 

9.  Ideomotor  Control.- — Sounds  occurring  simultaneously  with  sights, 
touches,  tastes,  smells,  emotion,  act  of  will,  etc.,  tend  to  be  connected 
with  them,  so  that  when  any  one  of  a  complex  group  occurs  again,  the 
others  are  revived  more  or  less  clearly  in  consciousness.  It  is  in  this 
way  that  speech  movements  become  associated  with  printed  letters. 

10.  General  Voluntary  Control. ^ — ^This  is  subject  to  changes  of  nutri- 
tion, fatigue,  emotion,  and  general  habits,  on  all  of  which  vocal  control 
must  place  its  dependence. 

The  author  is  indebted  to  Prof.  Carberry,  of  the  Wisconsin  Conser- 
vatory of  ]\Iusic,  for  the  following  suggestion,  which  has  proved  to  be 
exceedingly  useful  in  the  management  of  postoperative  speech-training 
cases.  As  vocal  instructor,  he  is  accustomed  to  teach  that  the  Italian 
a  is  the  basal  tone,  modification  of  which,  with  but  slight  alteration  of 
physiological  action,  allows  sufficient  change  to  utter  clearly  each  of 
the  other  ^'owels,  and  even  the  consonants.  With  the  organs  in  posi- 
tion to  make  this  tone  at  the  beginning  of  the  sound,  all  parts  are  under 
the  least  possible  strain.  The  resultant  sound  effect  therefore  will  be 
most  natural,  and  for  this  reason  can  be  carried  on  up  through  the 
various  registers  of  the  voice  to  higher  notes  without  sacrificing  purity 
as  must  necessarily  be  the  case  if  there  is  the  least  strain  upon  the 
voice  or  the  sound-producing  mechanism  connected  therewith  at  the 
moment  of  inception. 

Applications  of  this  principle  to  speech  training  show  that  the  con- 
fusing and  complicated  systems  which  in\olve  special  direction  of 
the  attention  to  lips  and  tongue  for  each  particular  letter  of  the  alphabet 
are  not  only  largely  unnecessary,  but  in  some  instances,  at  least,  most 
unadvisable.  For  with  overanxiety  causing  undue  nervousness  and 
tendency  to  unconscious  contraction  of  all  muscles,  and  the  added 
difficulties  of  other  speech  defects  induced  by  nervous  conditions,  that 
so  commonly  affect  these  patients  as  to  make  additional  complication, 
there  can  be  no  question  that  the  simpler  form  of  training  and  the  more 
devoid  of  multiplied  rules  of  procedure  such  instructive  methods  may 
be,  the  more  easily  and  rapidly  speech  improvement  will  take  place. 


BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE        659 

The  easiest  and  the  most  natural  way  to  overcome  these  unfortunate 
speech  habits  seems  to  be  the  use  of  the  voice  in  singing. 

Conclusions. — No  individual  with  cleft  palate,  no  matter  how  bad 
the  condition,  need  be  utterly  discom-aged. 

In  every  case  (age  being  no  contra-indication)  operation  for  closure 
of  palate  fissure  should  be  performed. 

No  unnecessarily  forcible  methods  should  be  employed  in  early 
infancy.  Defects  of  lip,  nose,  and  palate  due  to  imperfect  operative 
results,  which  are  frequent  causes  of  slow  speech  progress,  may  be 
much  benefited  by  corrective  operation. 

Avoid  complicated  methods  of  speech  training. 


BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE. 

BOOKS  AND  PAMPHLETS. 

Abel,  K. :  Eiii  Beitrag  zur  Statistik  der  Moralitat  nach  Haseascharten 
Operationen,  Gottingen,  1885. 

Ayasse,  M.:  Etude  Historiques  et  critique  des  precedes  de  restauration 
du  rebord  alv^olaire  dans  le  bec-de-lievre  complique,  Paris,  1897. 

Bein,  G.:     Zueiandftinfzig  Falle  von  Hasenscharten,  Bern,  1890. 

Berendsen,  G.:  Die  Esmarchsche  Methode  der  Hasenschartenoperation 
Kiel,  1883. 

Bidalot,  J.  F.:  Observations  de  varietes  rares  de  bec-de-lie\Te,  Strassburg, 
1867. 

Bosch,  B.:     Uber  das  Schicksal  der  Hasenschartenkinder,  Erlangen,  1892. 

Brandt,  L.:     Zur  Uranoplastik  Staphjiorrhapie  und  Prothese,  Berlin,  1888. 

Briinck,  "W. :  Sj'stematische  Untersuchung  des  Sprachorgans  bei  ange- 
borenem  Gaumendefect  in  ilirer  Beziehung  zur  Prognose  und  Therapie,  1906. 

Butcher,  R.  G.  H.:  Operative  JMeasures  Necessary  in  the  Treatment  of 
Harelip,  1856.     A  descrption  of  operations  on  different  types  of  harelip. 

Chaussier,  F.:  Description  et  usage  d'un  bandage  pour  le  bec-de-lievre, 
Paris,  1803. 

Courmont,  F.:  Des  Operations  applicables  au  bec-de-ne\Te  compHque, 
Paris,  1875. 

Denise,  A.:  Trait ement  du  bec-de-lie^Te  simple  et  comphque,  Paris  Thesis, 
1884. 

Deye,  S.     Ueber  Wolfsrachen,  Jena,  1904. 

D'Hour,  L.  H.:    Traitement  du  bec-de-lievre,  Lille,  1894. 

Dobberkan,  L.  J.:     Leber  Gaumenspalten,  Berlin,  1898. 

Elu-maim,  C.  H.:     Dissertation  sur  le  bec-de-lie^Te,  Strassburg,  1812. 

Eigenbrodt,  K.  Uebr  die  Hasenscharte,  ihre  operative  Behandlung  und 
deren  Erfolge,  Halle,  A.  S.,  1885. 

Fillebrown,  T. :  Reports  of  Operations  on  HareUp  and  Cleft  Palate,  Boston, 
1898. 

Fronhofer,  E.:  Die  Enstehung  der  Lippen-Kiefer-Gaumenspalte  m  Folge 
amniotisches  Adhasionen,  Berlin,  1896. 

Garretson,  J.  E.:  System  of  Oral  Surgerj',  Philadelphia,  Fifth  EcUtion, 
1890.  Chapter  XLIX,  Cleft  Palate;  Chapter  LIV,  HareUp;  favors  early 
operations. 

Garretson,  J.  E.:  Treatise  on  the  Diseases  and  Surgery  of  the  Mouth,  Jaws 
and  Associated  Parts,  1869.  Chapter  XXXV,  HareUp;  Chapter  XL,  Cleft 
Palate.     Discusses  the  proper  time  for  operation  and  the  operations. 


660        BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE 

Gourdon,  J.  J.  M.  L. :  Traitement  du  bec-de-lievre  corapliqu^,  Bordeaux, 
1897. 

Grant,  H.  H.:  Text-book  of  Surgical  Principles  and  Surgical  Diseases  of 
the  Face,  1902.  Chapter  XXIII,  Harelip  and  Cleft  Palate.  Describes  opera- 
tions. 

Greiner,  0.  H.  W.:  Zur  Aetiologie  und  Therapie  der  Hasenscharte,  Leipzig, 
1866. 

Groll,  0.:    Beitrage  zur  Statistik  der  Hasenscharte,  Wurzbiu"g,  1888. 

Henne,  0.:  Ziu-  Operativen  Behandlung  der  angeborenem  Gaumeaspalte, 
Leipzig,  1904. 

Hermann,  E.:  Beitrage  zur  Statistik  und  Behandlung  der  Hasenscharten, 
Breslau,  1884. 

Hosack,  A.  E.:     INIemoir  upon  Staphjdorrhaphj^,  New  York,  1833. 

Hullen,  M.:  Le  Pronostic  des  Urano  Staphylorrhapies  pour  Fissures 
congenitales,  Paris  Thesis,  1904. 

Hulhhen,  S.  P.:  Harehp  and  its  Treatment,  1844.  Twelve-page  pamphlet. 
Age  for  operation,  preparation  for  operation,  and  method  of  operation. 

Jourdain  BerchiUet,  A.  L.  B.:  Treatise  on  the  Diseases  and  Surgical 
Operations  of  the  Mouth,  1851,  p.  227.  Congenital  Defects  of  the  Palate  and 
Harelip. 

KoUiker,  T.:  Ueber  das  Os  intermaxillare  des  Alenschen  und  die  Anatomie 
der  Hasenscharte  und  des  WoKsrachens,  Halle,  1882. 

Lane,  G.  F.:     Cases  of  Complicated  Cleft  Palate,  London,  1854. 

Lane,  W.  A.:  Cleft  Palate  and  Harehp,  1905.  Causes;  best  age  for  opera- 
tions; technic  of  operation. 

Lane,  W.  A.:  Cleft  Palate;  Treatment  of  Sunple  Fracture,  etc.  Chapter 
I,  Cleft  Palate,  Harelip,  and  other  Comphcations. 

Liessner,  E.:     Zur  Kenntniss  der  Kiemenspalte,  Dorpat,  1889. 

Lorthior,  J.:     Operations  plastiques  de  la  bouche,  Brussels,  1901. 

Lo-ny,  A.:  Die  an  der  Koniglichen  Clururgischen  Klinik,  Breslau,  1891 
bis  1901,  behandelten  Falle  von  Hasenscharten,  Breslau,  1903. 

Marshall,  J.  S. :  A  Alanual  of  the  Injuries  and  Surgical  Diseases  of  the  Face, 
Mouth,  and  Jaws,  Pliiladelphia,  Second  Edition,  1902.  Chapters  XLIII  and 
XLIV,  Congenital  Fissm-es  of  the  Lip  and  the  Vault  of  the  Mouth,  and  their 
Surgical  Treatment. 

Mason,  F.:  On  Harehp  and  Cleft  Palate,  1877.  Harehp:  Types  and 
complications;  causes  and  hereditj^;  different  methods  of  operation.  Cleft 
palate:  Types;  feedmg  of  infants  with  cleft  palates;  causes  and  hereditary 
character;  age  for  the  operation;  different  methods  of  operation;  improvement 
in  voice. 

Mason,  F.:  Surgery  of  the  Face,  1879.  Chapter  III,  Harehp:  Different 
types;  hereditary  character;  method  of  operation.  Cleft  Palates:  Langen- 
beck's  operation;  Dieffenbach's  operation. 

]Muller,  E.:  Die  Hasenscharten  der  Tiibinger  Chirurgischen  Khnik,  1843- 
1885,  Tubingen,  1886. 

^Murray,  R.  W.:  Harehp  and  Cleft  Palate,  1902.  Causes  and  types  of 
harelip;  the  operation  for  harehp;  operation  for  double  harelip;  types  of  cleft 
palate;  age  for  operation;  technic  of  operation;  after-treatment. 

IMiitter,  T.  D. :  Report  on  the  Operation  for  Fissures  of  the  Palatine  Vault, 
Philadelphia,  1843. 

Napleson,  J.:  Observations  of  the  Treatment  of  Cleft  Palate,  London, 
1851. 

Neveu,  N.:    La  Voute  Palatine  en  Ogive,  Paris  Thesis,  1905. 

Owen,  E.:  Cleft  Palate  and  Harehp,  1904  (Medical  Monograph  Series). 
The  development  of  palate  and  hps  and  the  causes  of  cleft  palate  and  harelip; 
varieties  of  harehp;  technic  of  the  operations;  operation  for  harehp  in  infancy 
and  after  infancy;  care  after  the  operation;  the  operation  for  harelip,  and  the 
subsequent  treatment. 


BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE       661 

Owen,  E.:  Surgery  of  the  Mouth,  Teeth,  and  Jaws.  In  Keen's  Surgery, 
1908,  vol.  iii,  p.  614. 

Petaeu,  G. :  Contribution  h  I'etude  du  Traitement  du  bed-de-Hevre  double 
complique,  Blois,  1875. 

Preiswerk,  G.:  Atlas  and  Text-book  of  Dentistry,  including  Diseases  of 
the  Mouth,  Philadelphia,  1906.    Harelip  and  Cleft  Palate,  pp.  169  to  174. 

Rawdon,  H.  G.:  Operative  Treatment  of  the  Cleft  Palate  in  Children, 
Liverpool,  1880. 

Rieketts,  1?.  M.:    Surgery  of  Cleft  Palate,  Toledo,  0.,  1891. 

Ricketts,  B.  M.:  The  Surgery  of  Cleft  Palate,  1891.  A  paper  read  before 
the  Mississippi  Valley  Dental  Society  at  Cincinnati,  1891. 

Roberts,  John  B.  Surgical  Treatment  of  Congenital  and  Pathological 
Disfigurements  of  the  Face  (Mutter  Lectures,  College  of  Physicians  of  Phila- 
delphia, 1900).  Lecture  VI,  Harehp:  Different  forms;  causes;  operative 
treatment;  later  minor  operations  to  improve  appearances, 

Scheck,  P.:  Diseases  of  the  Mouth,  Throat,  and  Nose,  Edinburgh,  1886, 
p.  89,  Cleft  Palate.      . 

Sclmiitz,  E.  F.  J.:  Contribution  a  I'^tude  du  role  de  I'her^dite,  et  du  role  de 
I'amnols  dans  la  pathogenie  du  bec-de-lievre,  Paris  Thesis,  1904. 

Sinan,  A.  L.  M.:  Du  precede  de  Mirault  d' Angers  pour  Foperation  du 
bec-de-lievre  simple,  Paris,  1904. 

Texier,  Jean.:     Du  Traitement  du  bec-de-lievi'e  simple,  Paris  Thesis,  1905. 

Trabold,  K.  A.  M.:     Schadelform  un  Gaumenhohe,  Freiburg  u.  Br.,  1903. 

Uberholz,  F.  B.:  En  Beitrage  zu  den  Operationen  der  angeborenen 
Gaumenspalten,  1887. 

Warren,  J.  M.:     Fissure  of  the  Hard  and  Soft  Palate,  Pliiladelphia,  1865. 

Wheeler,  W.  I.:     Operative  Treatment  of  Harehp,  London  and  Dublin,  1887. 

Wolff,  J.:  Ueber  frlihzeitige  Operation  der  angeborenen  Gaimaenspalten, 
Leipzig,  1901  (Sanamlung  khnischer  Vortrager,  No.  301). 

PERIODICALS.! 

Abbe,  R.:    Harelip  and  Cleft  Palate,  Post  Graduate,  1895,  vol.  x,  p.  15. 

Anderson,  C.  M.:  The  Author's  Needle  for  Acutely  Arched  Cleft  Palate, 
New  Zealand  Medical  Journal,  1907,  vol.  v,  p.  1.  Application  de  la  prothese 
dentaire  a  la  reduction  des  becs-de-lievre  compliques.  Revue  ondotologique, 
1906,  vol.  XXV,  p.  387. 

Baldwin,  K.  W.:  Cleft  Palate  and  Harelip,  Laryngoscope,  1907,  vol.  xvii, 
p.  506. 

BarnhiU,  J.  F.:  The  Repair  of  Harehp  and  Cleft  Palate,  Laryngoscope, 
1908,  vol.  xviii,  p.  814. 

Berger :  Le  bec-de-lievre,  Revue  general  de  clinique  et  de  therapeutique,  1905, 
vol.  xix,  p.  326. 

Billhaut,  M.:  Bec-de-hevre  Annales  de  chirurgie  et  d'orthopedie,  1904, 
vol.  xvii,  p.  33. 

Bradford,  T.  G.:  Surgical  Operation  of  the  Labium  Frenum,  Texas  State 
Medical  Journal,  1907,  vol.  ii,  p.  234. 

Broca:  Bec-de-hevre  complexe  de  la  levi'e  superiem'e.  Revue  generale 
de  Clinique  et  de  Therapeutique,  1906,  vol.  xx,  pp.  1  to  81. 

Brophy,  T.  W.:  Anatomy  of  the  Palate,  Normal  and  Cleft,  Journal  of 
the  American  Medical  Association,  1907,  vol.  xlix,  p.  662. 

Brophy,  T.  W.:  Surgical  Treatment  of  Palatal  Defects,  Dental  Cosmos, 
April,  1901. 

Brown,  G.  V.  I.:  Clinical  Results  in  the  Surgical  Treatment  of  Harelip 
and  Cleft  Palate,  Dental  Cosmos,  1908,  vol.  i,  p.  123. 

'  For  earlier  periodical  literature  consult  the  United  States  Surgeon-General's  Cata- 
logue under  Harelip  and  Palate,  Cleft. 


6G2        BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE 

Brown,  G.  V.  I.:  Conservatism  in  the  Treatment  of  Infants  with  Harelip 
and  Cleft  Palate,  Journal  of  American  Medical  Association,  1907,  vol.  xlviii. 

Browni,  G.  V.  I.:  Surgical  Correction  of  Malformation  and  Speech  Defects 
Due  to  or  Associated  vAih  Cleft  Palate,  Journal  of  American  Medical  Associa- 
tion, 1902,  vol.  xxxiii,  p.  169. 

Brown,  G.  V.  I.:  Surgical  Correction  of  Malformation  and  Speech  Defects 
Due  to  or  Associated  with  Harehp  and  Cleft  Palate,  Journal  of  American 
Medical  Association,  January  18  and  25,  1902. 

Bro^Ti,  G.  V.  I.:  A  System  for  the  Surgical  Correction  of  Harehp  and  Cleft 
Palate,  Journal  of  American  Medical  Association,  1905,  vol.  xhv,  p.  848. 

Bro^-n,  G.  V.  I.:  Speech  Results  of  Cleft  Palate  Operation,  Journal  of  the 
American  Medical  Association,  1908,  vol.  1,  p.  3-42. 

Cahdn,  W.  D.:  Etiologj-  of  Harehp  and  Cleft  Palate,  Dental  Digest,  1908, 
vol.  xiv,  p.  1508. 

Cai-mody,  T.  E. :    Cleft  Palate,  Colorado  Medicine,  1908,  vol.  v,  p.  313. 

Case,  C.  S.:  Mechanical  Treatment  of  Congenital  Cleft  Palate,  Trans- 
actions of  the  International  Dental  Congress  for  1905,  p.  129;  also  in  Dental 
Cosmos,  1905,  vol.  xlvu,  p.  1037. 

Chauveau,  C:  AnomaUe  Palato-StaphyUenne,  "Archives  International  de 
Laryngologie,  1907,  vol.  xxiii,  p.  297. 

Coomes,  ^l.  F.:  Malformations  of  the  Mouth  and  Cleft  Palate;  American 
Practitioner  and  News,  1908,  vol.  xhi,  p.  97. 

Craig,  A.  R. :  Repairing  of  Clefts  of  the  Palate  and  the  Lip,  Pennsylvania 
Medical  Journal  for  1907-1908,  p.  214. 

Delang^niere,  H.:  Du  veritable  proc^de  de  Mirault,  d' Angers  pour  I'opera- 
tion  du  bec-de-he\Te,  Archives  pro\'inciales  de  chirurgie,  1903,  vol.  xii,  p.  717. 

Dumont,  J.:  A  propos  de  I'operation  de  bec-de-he\Te,  Presse  medicale, 
1905,  p.  517. 

Dunliam,  T. :     Operation  for  Harehp,  Post-Graduate,  1897,  vol.  xii,  p.  603. 

Dunham,  T.:  Retention  Method  after  Harehp  Operations,  Annals  of 
Surgerj',  1905,  vol.  xhi,  p.  593. 

Eastman,  J.  R.:  Newer  Conceptions  of  Operative  Technic  in  Cleft  Palate 
and  Harehp,  Annals  of  Surgery,  1909,  vol.  xlix,  p.  35. 

Ferguson,  A.  H.:  Harelip  and  Cleft  Palate,  Transactions  of  the  Southern 
Surgical  and  Gynecological  Association,  1908,  vol.  xx,  p.  278. 

Fillebrown,  T.:  A  study  of  Harelip  and  Cleft  Palate,  Proceedings  of  the 
Massachusetts  Dental  Society,  1897,  vol.  xxxui,  p.  68. 

Gaucher:    Bec-de-lie\Te,  Journal  Medecine  Interne,  1908,  vol.  x,  p.  21. 

Graddy,  L.  B.:  A  Satisfactory  Operation  for  Harelip,  Medical  Brief,  1905, 
vol.  xxxiu,  p.  713. 

Haug,  G. :  Beitrage  zur  Statistik  der  Hasenscharten,  Beitrage  zur  klinischen 
Chirurgie,  1904,  vol.  xhv,  p.  254. 

HajTnann,  T.:  Amniogene  und  erbhche  Hasenscharten,  Archiv  ftir 
kUnische  Clururgie,  1903,  vol.  Ixx,  p.  1033.     Also  reprint,  Berlin,  1903. 

Hentze:  Ueber  Hasenscharten  und  Wolfsrachen  und  deren  Behandlung, 
Deutsche  Monatsschrift  fiir  ZahnlieiUcunde,  1905,  vol  xxiu,  p.  539. 

Kiimisson:  Le  bec-de-he\Te  et  son  Traitement,  Medecine  moderne,  1904, 
vol.  XV,  p.  185;  also,  Annales  de  Medecine  et  chirurgie  infantiles,  1903,  vol.  \ii, 
p.  472. 

Kirmisson:  Traitement  du  bec-de-he^Te  double  et  comphque.  Gazette 
de  maladies  infantiles,  1903,  vol.  v,  p.  81. 

Kiister:  Zur  Operation  der  comphcierten  Hasenscharte,  Zentralblatt  fiir 
Chirurgie,  1905,  vol.  xxxu,  p.  713. 

Lane,  W.  A.:     Modern  Treatment  of  Cleft  Palate,  Lancet,  1908,  vol.  i,  p.  6. 

Lorenz,  R. :  Eine  neue  Operations  methode  fiir  doppelseitige  Hasenscharte, 
Deutsche  Zeitschrift  fiir  Chirurgie,  1907,  vol.  lxxx\-ii.  p.  410. 

Lo^\Tnan,  W.  H.:  ^Median  Harehp,  British  Medical  Journal,  1904,  vol.  i,  p. 
892. 


BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE        GG5 

Lucas,  R.  C. :  On  an  Ill-developed  Upper  Lateral  Incisor  Tooth  as  a  Fore- 
runner of  Harelip  or  Cleft  Palate,  Report  of  Society  for  the  Study  of  the 
Diseases  of  Childhood,  London,  1905,  vol.  v,  p.  31. 

McGraw,  T.  A.:  Unsettled  Questions  in  the  Treatment  of  Harelip  and 
Cleft  Palate,  Detroit  Medical  Journal,  1908,  vol.  viii,  p.  1. 

McKernon,  J.  F. :  Congenital  Cleft  of  the  Palate  .  .  .  the  Operative 
Technic  and  its  Results,  Larjiigoscope,  1903,  vol.  xiii,  p.  97. 

McKernon,  J.  F.:  Contribution  to  the  Technic  of  Modern  Uranoplasty, 
New  York  :Medical  Journal  1900,  vol.  Ixxi,  p.  933. 

Makuen,  G.  H.:  Cleft  Palate  and  its  Relation  to  Speech,  American  Medi- 
cine, October  5,  1901. 

Makuen,  G.  H.:  Operations  for  Cleft  Palate  and  Theii-  Results,  Especiallj^ 
in  the  Improvement  of  Speech,  New  York  Medical  Journal,  1907,  vol.  Ixxxvi, 
p.  146. 

Mauley,  J.  H.:  Harelip:  Its  Causes  and  Treatment.  International  Medi- 
cal Magazine,  1893,  vol.  ii,  p.  209. 

Morris,  R.  T.:  HareUp,  American  Jom-nal  of  Sm'gery  and  G^mecologv, 
1899,  vol.  xiii,  p.  139. 

Miiller,  W.  B. :  Die  Operation  der  Hasenscharte,  Kinderarzt,  1908,  vol.  xix, 
p.  49. 

Mumford,  J.  G.:  Medical  and  Surgical  Treatment  of  HareUp,  Boston 
Medical  and  Surgical  Journal,  1898,  vol.  cxxx\dii,  p.  198. 

Murray,  R.  W.:  At  What  Age  Should  a  Cleft  Palate  be  Closed?  Pedi- 
atrics, 1907,  vol.  xix,  p.  73. 

Murray,  R.  W.:  Geographical  Distribution  of  Harelip  and  Cleft  Palate, 
Lancet,  1904,  vol.  i,  p.  1423. 

Peck,  C.  H.:  Operative  Treatment  of  Cleft  Palate,  Annals  of  Surgery, 
1906,  vol.  xliii,  pp.  5  and  126. 

Piechaud,  T. :     Un  point  du  technique  sm:  I'operation  du  bec-le-lievre. 

Putnam,  C.  H.  L. :  Harelip  and  its  Treatment,  Pediatrics,  1904,  vol.  xvi, 
p.  81;  also  Post-Graduate,  1903,  vol.  x\iii,  p.  868. 

Racliford,  B.  K.:     HareUp,  Archives  of  Pediatrics,  1902,  vol.  xix,  p.  100. 

Reiss,  W.  A.:    A  Harelip  Operation,  Dental  Brief,  1906,  vol.  xi,  p.  83. 

Roberts,  J.  B. :  Modern  Method  in  the  Repair  of  the  Cleft  Palate,  Larjiigo- 
scope,  1907,  vol.  x\ii,  p.  501;  also  American  Journal  of  Medical  Sciences,  New 
Series,  1907,  vol.  cxxxiv,  p.  87;  also  reprint. 

Rocher:  Quelques  Considerations  embryologiques  sur  la  pathogenie  due 
bec-de-lie\Te,  Journal  de  Medecine  de  Bordeaux,  1904,  vol.  xxxiv,  p.  530. 

Sherman,  H.  M.:  Some  Technical  Points  in  the  Cleft  Palate  Operation, 
Surgery,  Gynecology'  and  Obstetrics,  1908,  vol.  vi,  p.  644;  also.  Transactions  of 
American  Surgical  Association,  1908,  vol.  xxvi,  p.  609. 

Singley,  J.  De  V. :  Operative  Treatment  of  Cleft  Palate  and  the  Causes  of 
Failure,  American  Medicine,  1905,  vol.  x,  p.  490. 

Smith.  D.  T.:  Cleft  Palate,  Surgery,  Gynecology'  and  Obstetrics,  1907, 
vol.  xxix,  p.  223. 

Starr,  F.  N.  G.:  Cleft  Palate  and  HareUp,  International  Clinics,  18th 
Series,  1918,  vol.  iii,  p.  171. 

Starr,  F.  N.  G.:  New  ^Method  of  DeaUng  with  Cleft  Palate,  Canadian 
Jom-nal  of  Medicine  and  Surgery,  1907,  vol.  xxi,  p.  349. 

Stone,  J.  S.:  HareUp  and  Cleft  Palate,  Bryant  and  Buck,  American  Prac- 
tice of  Surgery,  1908,  vol.  v,  p.  500. 

Taylor,  A.  S.:  A.  Dressing  after  HareUp  Operation,  Journal  of  American 
Medical  Association,  1907,  vol.  xl\'ii,  p.  209. 

TomUnson,  E.  S.:  Cleft  Palate:  Its  Origin,  Effect,  and  Treatment,  Dental 
Cosmos,  1906,  vol.  xlviU,  p.  658. 

Vance,  A.  M.:  Points  in  Teclinic  of  Cleft  Palate,  Surgerj',  Gynecology  and 
Obstetrics,  1907,  vol.  iv,  p.  343. 


664        BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE 

Warnekros:  Gaumenspalten,  Archiv  fiir  Laryngologie  und  Pthinologie, 
1908,  vol.  xxi,  p.  144. 

Waugh,  G.  E.:    Operation  for  Cleft  Palate,  Lancet,  1905,  vol.  ii,  p.  1504. 

Wharton,  H.  R.:  Cleft  Palate,  Pennsylvania  Medical  Journal,  1906, 
vol.  X,  p.  99. 

Whitehead,  W.  R. :  Report  on  the  Best  Methods  of  Treatment  for  Different 
Forms  of  Cleft  Palate,  Transactions  of  American  Medical  Association,  1869; 
also  reprint. 

Wies,  H.:  Prognose  der  Ha.'^enscharten  Operationen,  Annalegen  der 
stadtischen  der  allgemeinen  Krankenhaiiser  zu  Miinchen,  1901,  vol.  xi,  p.  245. 

Winternitz,  A.:  Operation  der  Gaumenspalte  mittelst  Platennaht,  Archiv 
fiir  khnische  Chirurgie,  1908,  vol.  Ixxxvi,  p.  643. 

Woollcombe,  W.  L. :  Mandibular  Processes  Associated  vdih  Double  Harelip 
and  Cleft  Palate,  Lancet,  1905,  vol.  i,  p.  357. 

Young,  J.  K. :  Treatment  of  HareUp,  International  Medical  Magazine, 
1900,  vol.  ix,  p.  821. 

RECENT  LITERATURE. 

'  Ambridanne:  Restauration  d'un  bec-de-he^Te  Complet  Avec  Fente  du 
Palais  et  du  Voile,  Chez  un  Enfant  de  Deux  Jours,  Bulletin  et  Memoii'es  de  la 
Societe  de  Chirurgie  de  Paris,  1913,  vol.  xxxix,  p.  1506. 

Barge,  J.  A.  H.:  Hazenlip  en  Scheeve  Gesichtsplect  Volgens  Nieuwere 
Onderzoekingen.  Tydscher  V.  Geneesk  Amst.,  1914,  vol.  ii,  pp.  1416-1498, 
(Full  name  of  periodical  uiikno'mi.) 

Bater:  Hagendom's  Operation  for  Harelip  and  Cleft  Palate,  Lancet,  1916, 
vol.  i,  p.  136. 

Berrj',  J. :  Surgerj-  of  the  Cleft  Palate,  Surgery,  Gynecology  and  Obstetrics, 
1915,  vol.  XX,  pp.  85-87. 

Blader,  W.  F. :  Heredity  as  a  Factor  in  Congenital  HareUp  and  Cleft  Palate, 
Dental  Cosmos,  Philadelphia,  1914,  vol.  Ivi,  pp.  1241-1245. 

Blakewav,  H.:  The  Treatment  of  Harelip  and  Cleft  Palate,  Practitioner, 
London,  1914,  vol.  xcii,  pp.  219-239. 

Blakeway,  H.:  The  Effects  of  Cleft  Palate  Operations  on  the  Dental  Arch, 
Practitioner,  London,  1915,  vol.  xcv,  pp.  145-169. 

Brophy,  T.  W.:  The  Late  Results  of  Cleft  Palate  Operations,  Surgery, 
Gj'necolog}''  and  Obstetrics,  1915,  vol.  xx,  pp.  98-100. 

Brown,  G.  V.  I.:  The  Principles  Which  Govern  the  Ultimate  Results  of 
Harelip  and  Cleft  Palate  Operations,  Lancet,  London,  1914,  vol.  ii,  pp.  587-691. 

Brown,  G.  V.  I.:  The  Principles  Which  Govern  the  Ultimate  Results  of 
Harelip  and  Cleft  Palate  Operations,  Surgerj',  Gynecolog}^  and  Obstetrics, 
1915,  vol.  XX,  pp.  87-91. 

Brj-an,  W.  A.:  Operative  Correction  of  Harelip  and  Cleft  Palate,  Southern 
Medical  Journal,  1915,  vol.  viii,  pp.  218-222. 

Carmody,  T.  E. :    Cleft  Palate,  Colorado  Medicine,  1914,  vol.  ii,  pp.  90-106. 

Caimcdy,  T.  E. :     (Title  not  listed)  Southern  Medical  Journal,  vol.  ix,  p.  744. 

Cole,  H.  P.:  Harelip  Surgerj^;  Essentials  in  the  Production  of  Scarless 
Incisions,  Southern  Medical  Journal,  1915,  vol.  viii,  pp.  790-796. 

Drachter,  R.:  Zur  Frage  der  Verschliisse  der  Kieferspalte  bei  "Einseitig 
Durchziehender  Gaumenspalte,"  Zentralblatt  f.  Chirurgie,  1914,  vol.  xU, 
pp.  497-499. 

Drachter,  R.:  Die  Gaumenspalte  und  Deren  Operative  Behandlung, 
Deutsche  Zeitschrift  fiir  Chirurgie,  1914,  vol.  cxxxi,  pp.  1-89. 

Drachter,  R.:  Die  Gaumenspalte  und  Deren  Operative  Behandlung, 
Miinchener  medizinische  Wochenschrift,  1914,  vol.  Ixi,  p.  1624. 

Easlman,  J.  R. :  Factors  of  Safety  in  Cleft  Palate  Surgery,  Lancet,  London, 
1914,  vol.  ii,  pp.  312-315. 


BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE        665 

Eastman,  J.  R.:  Factors  of  Safety  in  Cleft  Palate  Surgery,  Surgery, 
GjTiecology  and  Obstetrics,  1915,  vol.  xx,  pp.  91-95. 

Eastman,  J.  R. :  The  Surgical  Anatomy  of  Cleft  Palate,  Journal  of  American 
Medical  Association,  1915,  vol.  Ixv,  pp.  915-920. 

Eifert:  Herstellung  von  Obturatoren  flit  den  Weichen  Gaumen  (I^igene 
Methode).     Deutsche  Zahnheilkunde  im  Vortrag,  1914,  Heft,  33,  S.  49-56. 

Emerson,  L. :  Operations  for  Clefts  of  the  Hard  and  Soft  Palate,  Journal 
of  American  Medical  Association,  1915,  vol.  Ixiv,  pp.  301-305. 

Farr,  R.  E.:  The  Management  of  Harelip  and  Cleft  Palate  Cases,  Journal- 
Lancet,  Minneapolis,  1914,  vol.  xxxiv,  pp.  4S1-489. 

Froschels,  E.,  and  Klein:  Wolfsrachen  und  Hasenscharte,  "Wiener  klinische 
Wochenschrift,  1914,  vol.  xxvii,  p.  587. 

Hazemann,  R.:  Fine  Zweckmassige  Modifikation  des  Heftpflasterver- 
bandes  bei  Hasenscharten  Operationen,  Zentralblatt  f.  Cliirurgie,  1914,  vol. 
Ixi,  p.  884. 

Hans,  H.:  Zur  Operationstechnik  der  doppelseitigeu  Hasenscharte,  Zentral- 
blatt f .  Chirurgie,  "Leipzig,  1914,  vol.  xli,  p.  1357. 

Helbing,  C:  Zlu"  Frage  der  Heft  pilaster  verbandes  bei  Hasenscharten- 
Operationen,  Zentralblatt  f.  Chirurgie,  Leipzig,  1914,  vol.  xli,  p.  1385. 

Holf elder:  Heftpflasterverband  bei  Hasenschartenoperationen,  Zentral- 
blatt f.  Cliii'urgie,  Liepzig,  1914,  vol.  xli,  p.  1145. 

Kaerger,  E.:  Die  Brophysche  Gaumenspaltenbehandlung,  Deutsche  medi- 
zinische  Wochensclirift,  Leipzig  und  Berlin,  1913,  vol.  xxxix,  p.  2552. 

Kaerger,  E.:  Brophysche  Gaumenspaltenbehandlung,  Deutsche  medizin- 
ische  Wochenschrift,  Leipzig  und  Berhn,  1913,  vol.  xxxix,  p.  2573. 

Kaerger,  E.:  L'eber  die  Behandhmg  der  Angeborenen  Kiefer  und  Gaumen- 
spalten  unter  Besonderer  Beriicksichtigung  der  Frtih-Operation  und  der 
Methode  nach  Brophy,  Arcliiv.  f.  klinische  Cliirurgie,  Berlin,  1914,  vol.  ciii, 
pp.  255-349. 

KejTion,  E.  L.:  The  Speech  Aspects  of  a  Case  of  Cleft  Palate,  Journal  of 
Ophtiiahnology  and  Oto-Laryngolog>',  Chicago,  1915,  vol.  ix,  pp.  102-104. 

Kej'-non,  E.  L.:  The  Speech  Aspects  of  a  Case  of  Cleft  Palate,  Illinois 
Medical  Journal,  Cliicago,  1914,  vol.  xxvi,  p.  622. 

Ladd,  W.  E.:  Modification  of  Technic  for  Harelip  Operation,  Boston 
Medical  and  Surgical  Journal,  1915,  vol.  clxxii,  pp.  54-56. 

Lenormant.  C:  Le  Traitement  de  Divisions  Congenitales  du  Palais  par 
la  Methode  de  Brophv,  a  Propos  d'une  Statistique  Recente,  Presse  Medicale, 
Paris,  1914,  vol.  xxii,  pp.  167-169. 

Levi,  G. :  A  Proposito  di  una  Fessura  Labio  ISIaxillo  Palatina  in  un  Giovane 
Embrione  Umano,  Ginecol.  Mod.  Geneva,  1914,  vol.  vii,  pp.  260-276. 

MacKenty,  J.  E.:  Operative  Treatment  of  Cleft  Palate,  Transactions  of 
American  Larjaigological  Association,  1914,  vol.  xxxvi,  pp.  273-291. 

Matti,  H.:  Zweckmassiger  Verband  nach  Hasenschartenoperation,  Zentral- 
blatt f.  Cliirurgie,  Leipzig,  1914,  vol.  xU,  pp.  1386-1388. 

Meige,  H.:  Un  bec-de-lievre  en  Peinture  et  Quelques  Remarques  sur  la 
Conformation  des  Le^Tes,  N.  iconog.  de  la  Salpetriere,  Paris,  1914,  vol.  xx\ai, 
pp.  57-60. 

^Mitchell,  V.  E.:  Artificial  Restoration  of  Lost  or  Missing  Tissues  in  Con- 
genital Cleft  Palate,  New  De\dce,  American  Journal  of  Surgery,  March,  1917, 
vol.  xxxi,  p.  57. 

Nicholl,  J.  H.:  Operative  Treatment  of  Cleft  Palate  and  Harelip,  Glasgow 
Medical  Journal,  January,  1917,  vol.  Ixxxvii,  p.  16. 

Nicholl,  J.  H.:  Operations  for  Harehp  in  the  Out-patient  Department, 
Edmbm-gh  Medical  Journal,  1913,  vol.  xi,  pp.  419-421. 

Neumann,  W.:  Die  "Normierung"  des  Oberkiefers  bei  Kompletter  Kiefer- 
spalte,  Berliner  klinische  Wochenscrift,  1914,  vol.  li,  p.  294. 

Riegner:  Die  Prothesenbeiiandlung  der  Gaumenspalten,  Beitrage  zur 
kliniochen  Chirurgie,  1914,  vol.  xci,  pp.  569-577. 


6GG        BIBLIOGRAPHY  FOR  HARELIP  AND  CLEFT  PALATE 

Schoemaker,  J.:  Zur  Technik  der  Uranoplastik,  Zentralblatt  f.  Cliirurgie, 
1914,  vol.  xli,  p.  1514. 

Smith,  Herbert  L. :  Apparatus  for  Use  after  Operations,  Surgery,  Gynecol- 
ogy and  Obstetrics,  November,  1916,  vol.  xxiii,  p.  628, 

Soyder,  F.  W. :  On  the  Treatment  of  Cleft  Palate,  Surgery,  Gynecology  and 
Obstetrics,  1915,  vol.  xx,  pp.  95-97. 

Thompson,  G.  S.:  Nasal  Flap. and  Modified  Langenbeck  Operations  for 
Cleft  Palate,  Lancet,  London,  1915,  vol.  i,  p.  1288. 

Todd,  A.  H.:  Case  Showing  Bilateral  Harelip  without  Cleft  Palate,  and 
also  Congenital  Bilateral  Mucous  Fistulte  in  the  Lower  Lip,  Proceedings  of  the 
Royal  Society  of  Medicine,  1913-14,  vol.  vii.  Section  on  the  Study  of  the 
Diseases  of  Children,  p.  132. 

von  TotMalussy,  E.:  Die  Hasenscharte,  Ergebnis&e  der  Chirurgie  und 
Orthopadie,  1913,  vol.  vii,  pp.  409-453. 

Welch,  Rowe,  and  Lehnhoff:  Complete  Unilateral  Harelip  and  Cleft 
Palate,  Nebiaska  Medical  Journal,  February,  1917,  vol.  ii,  p.  246. 

Wilkinson,  0.:  The  Use  of  Aluminum  Plates  in  Cleft  Palate  Operation, 
Virginia  Medical  Semi-monthly,  1913,  vol.  xviii,  p.  481. 

Witherspoon,  L.  G.:  Harelip  and  Cleft  Palate,  Bulletin  of  El  Paso  County 
Medical  Society,  1913,  vol.  v,  pp.  18-26. 


CHAPTER  XIV. 

THE  TREATiSlEXT  OF  WOUNDS  UNDER  WAR 
CONDITIONS. 

The  experiences  of  the  war  in  Europe,  with  wholesale  destruction 
of  tissue  by  an  infinite  variety  of  projectiles  and  the  ever-present 
dangers  from  battlefields  planted  with  pyogenic  microorganisms 
through  centuries  of  fertilization  with  manure,  the  diseases  of  the 
trenches,  the  inhalation  of  poisonous  gases,  the  burns  of  flames  sent 
broadcast  among  the  soldiery,  frost-bite,  the  diseases  of  exposure  and 
unsanitary  conditions,  have  so  changed  the  order  of  routine  treatment 
of  woiuids  that  had  previously  been  found  to  be  satisfactory  under 
ordinary  conditions  that  a  work  of  this  character  would  be  incomplete 
without  at  least  a  brief  reference  thereto. 

Tetanus.^The  horrors  of  tetanus,  whenever  the  antitetanic  serum 
could  be  procured,  have  been  largely  prevented  by  the  early  injection 
of  the  serum  in  all  cases  of  serious  wounds. 

Infection  by  Gas-producing  Organisms.^ — According  to  INIackenzie 
Forbes,  "these  are  of  the  anaerobic  variety.  The  bacillus  of  malignant 
edema  is  the  most  conmion.  ]\Iore  rarely  found  is  the  Bacillus 
aerogenes  capsulatus  (Welch).  Infections  by  these  organisms  are 
characterized  by  their  virulency.  It  is  necessary  to  recognize  them 
early,  because  at  first  the  infection  is  local,  although  usually  of  a  deep 
wound,  and  practically  always  of  the  lower  extremity. 

"A  wound  so  infected  is  dirty  in  appearance.  It  "contains  pus,  or 
pseudopus,  with  a  fecal-like  odor,  which  is  similar  to  liquid  feces  in 
color  and  consistency.  The  parts  about  it  are  swollen  and  congested, 
but  at  this  stage  no  characteristic  crackling  can  be  elicited  by  palpating 
the  surrounding  tissues;  thus  it  may  be  difficult  to  differentiate  it 
from  an  infection  by  the  colon  bacillus.  Later  there  may  be  localized 
gangrene  around  the  wound,  about  which  crackling  can  be  elicited  on 
careful  palpation.  In  some  cases  this  latter  may  be  noticed  without  a 
suggestion  of  gangrene.  The  condition  at  first  is  really  one  of  cellulitis. 
The  patient's  general  condition,  which  is  due  to  toxemia,  is  often  far 
worse  than  is  suggested  by  the  local  lesion.  In  those  cases  in  which 
crackling  is  found  on  palpation  there  can  be  no  doubt  as  to  either 
diagnosis  or  treatment.  In  the  earliest  stages,  in  which  there  is  doubt 
as  to  the  diagnosis,  open  freely  and  drain.  When  crackling  is  found, 
treat  at  once  as  for  a  fulminating  cellulitis,  where  the  freest  incisions 
and  drainage  are  indicated.  At  the  same  time  hydrogen  dioxide  may 
be  injected  into  the  surrounding  subcutaneous  tissues  in  an  attempt  to 
limit  the  infection.  The  infected  area  must  be  kept  under  constant  sur- 
veillance, always  remembering  that  to  save  life,  amputation  in  the  case 

1  Notes  on  War  Surgery,  British  Med.  Jour.,  p.  369. 

(667) 


668       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

of  a  limb  may  be  necessitated  at  any  time.  When  gangrene  has  appeared, 
amputation  is  necessary.  This  may  be  done  through  the  emphysema- 
tous tissues  if  the  open  methods  to  be  described  later  are  employed. 

"  In  dealing  with  infections  by  gas-forming  organisms  it  is  necessary 
to  keep  in  mind  that  the  patient's  life  is  endangered  from  the  very 
beginning,  and  although  early  and  very  free  incisions  may  relieve  the 
patient  even  in  cases  in  which  we  are  dealing  with  a  cellulitis  alone, 
amputation  with  free  drainage  may  often  have  to  be  resorted  to  in  the 
end  in  order  to  save  the  patient's  life." 

Morriss^  calls  attention  to  the  fact  that  "modern  trench  warfare 
created  an  unexpected  situation,  and  at  present  the  military  surgeon 
faces  problems  which  in  some  respects  are  novel.  A  maiority  of  the 
Mounds  are  caused  by  pieces  of  shell  and  shrapnel  balls,  and  generally 
these  are  infected.  Even  rifle  wounds  are  rarely  aseptic,  for  the  range 
is  short  and  the  explosive  violence  correspondingly  increased.  Shatter- 
ing of  the  bone  and  hernia  of  muscle  are  common.  These  conditions, 
resembling  those  in  wounds  caused  by  low- velocity"  projectiles,  nearly 
always  lead  to  suppuration.  Accordingly  all  wounds  are  treated  from 
the  first  as  if  infected,  and  antiseptics  are  used  with  Listerian  rigor." 

Bull  has  recently  elaborated  a  gas-gangrene  bacillus  antitoxin,  by 
the  injection  of  which  he  claims  both  growth  and  toxic  absorption  are 
inhibited." 

Antiseptics. — Since  practically  all  wounds  are  infected  and  great 
enlargement  usually  is  necessary  because  clothing,  foreign  bodies  of 
various  kinds  and  other  infective  agents  are  driven  into  the  tissues  by 
projectiles,  and  especially  because  the  frightful  sloughing  and  edema- 
tous conditions  of  the  tissue  require  extensive  incisions  for  relief  and 
drainage,  as  well  as  large  exposed  areas  in  which  portions  of  the  body 
have  been  torn  away,  the  problem  of  combating  infections  by  the  use 
of  antiseptics  is  a  very  serious  one.  A  natural  result  of  this  has  been  the 
trying  out  in  the  various  base  and  other  hospitals  of  practically  all 
known  antiseptic  agents.  The  net  result  of  this  has  been  the  general 
adoption  of  the  use  of  Dakin's  fluid. 

Daliirs  sohition^  is  an  aqueous  solution  of  0.5  per  cent,  concentration 
of  sodium  hypochlorite,  and  is  made  as  follows:  Tissolve  in  a  large 
bottle  140  grams  of  dry  carbonate  of  soda  with  10  liters  of  sterile  water. 
Add  to  this  200  grams  of  chloride  of  lime  (bleaching  powder)  and  shake 
well.  After  half  an  hour  siphon  off  the  clear  fluid  into  another  bottle 
through  cotton  or  filter  paper  and  then  add  40  grams  of  boric  acid  to  the 
clear  filtrate.  This  solution  is  neutral  to  litmus,  is  non-irritating  and  is 
the  proper  strength  for  wet  dressings  and  irrigations.  A  stronger  stock 
solution  of  4  per  cent,  may  be  made,  but  the  quantity  of  boric  acid  to  be 
added  must  be  determined  exactly,  so  that  the  solution  is  just  acid  to 
phenolphthalein  suspended  in  water;  otherwise  the  solution  decom- 
poses very  quickly.    The  solution  should  be  made  fresh  every  three  or 

1  The  Military  Surgeon,  xxxviii,  131. 

*  Report  of  Demonstration  before  the  National  Council  of^  Defense. 

'Harnbogen:  Journal  of  Michigan  State  Medical  Society,  September,  1917. 


INFECTION  BY  GAS-PRODUCING  ORGANISMS 


669 


four  days,  and  the  dry  stock  ingredients  should  be  kept  in  covered 
receptacles.  Besides  its  proved  efficiency,  another  point  worthy  of  con- 
sideration is  that  this  solution  can  be  made  up,  even  in  small  amounts, 
at  a  cost  of  only  about  five  cents  for  10  liters. 

The  advantages  claimed  for  sodium  hypochlorite  solution  in  the 
treatment  of  septic  wounds  are:  (1)  The  simplicity  and  cheapness  of 
preparation  of  the  antiseptic.  (2)  It  is  non-toxic  and  non  irritating  to 
the  tissues  when  properly  prepared  according  to  Dakin's  formula;  the 
hypochlorite  solution  may  be  safely  used  in  large  quantities  over  long 
periods  of  time  without  ill  effects.  (3)  The  deodorant  action  of  the 
solution  is  remarkable;  the  fetor  from  gangrenous  tissue  usually 
disappears  in  twenty-four  hours.  (4)  The  rapidity  with  which  sloughs 
separate  and  clean  granulation  tissue  is  forced  in  a  wound  under  its 
influence.  (5)  The  infreqaency  of  redressing  required  by  cases  treated 
with  hypochlorite  compared  with  the  constant  change  of  dressing 
required  in  large  wounds  with  other  forms  of  antiseptics.  (6)  The 
fact  that  injections  of  the  hypochlorite  solution  into  rubber  tubes  used 
in  the  dressings  may  with  safety  be  entrusted  to  very  imperfectly 
trained  orderlies  without  fear  of  ill  results,  once  the  case  has  been 
adequately  dealt  with  by  the  surgeon. 

Dichloramine-T,  Dakin's  latest  antiseptic  solution,  twenty  times  as 
powerful  as  the  watery  solution  used  in  the  Carrel  method,  is  dissolved 
in  oil  of  eucalyptus  and  applied  by  a  spray. ^ 

The  therapeutic  value  of  this  agent  is  now  universally  recognized. 


Fig.  506. — Carrel's  apparatus  for  administering  Dakin's  solution. 

Carrel's  Method  (Figs.  506,  507  and  508).— The  Carrel  tube  is  made 
by  placing  a  perforated  rubber  tube  one-quarter^of  an  inch  in  diameter 

1  Le  Conte;  Report  of  the  National  Counsel_of  Defense. 


670       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

in  cloth  of  coarse  material,  as  rough  toweling.  One  thickness  is  placed 
around  the  tube  and  sewed.  These  tubes  in  different  lengths  are  placed 
in  the  tract  made  by  the  missile,  through  the  wound  of  entrance  and 
through  the  wound  of  exit,  lying  alongside  of  each  other  in  the  tract. 
The  solution  is  then  injected  every  two,  three  or  four  hours,  or  can  be 
used  continuously.    Dr.  Carrel  advises  that  in  the  wound  there  should 


Fig.  507. — Carrel  instillation  apiiaratus.     The  receptacle  is  blackened  to  prevent 
decomposition  of  the  hypochlorite  solution  by  sunlight. 


Fig.  508. — Cairel's  method  as  applied  in  treatment  of  leg  wound. 


not  be  any  effort  made  on  the  part  of  the  surgeon  to  clean  out  the 
foreign  particles  of  dirt;  in  fact,  no  disturbance  of  the  wound  in  any 
way,  but  it  has  been  our  custom  to  clean  out  all  blood  clots.  This 
solution  seemed  to  give  the  best  results  in  cases  that  had  received  their 
injury  only  a  few  hours  previously.  The  tubes  were  generally  left  in  the 
wound  from  twelve  to  fourteen  days,  and  upon  removal  the  wounds 
seemed  to  heal  very  rapidly.    The  exudate  was  never  as  abundant  as  in 


IMMEDIATE  THE  AT  ME  NT  OF  WAR  INJURIES  671 

the  other  cases  and  did  not  have  the  appearance  of  pus  but  that  of  a  thin 
colorless  jelly-like  substance. 

Hypertonic  and  Isotonic  Salt  Solutions. — The  attempts  on  the  part 
of  the  surgeon  to  increase  the  combative  forces  of  the  body  are  at 
times  very  discouraging,  and  there  are  several  things  that  have  to  be 
taken  into  consideration.  The  one  word  stim.nlation  will  cover  a  great 
deal  of  it;  first,  the  stimulation  of  the  physiological  forces;  second, 
that  of  the  protective  elements,  and,  third,  that  of  the  action  of  the 
white  blood  corpuscles  (phagocytosis).  It  may  be  said  that  the  action 
of  salt  solutions  has  been  known  for  many  years,  but  the  use  of  solutions 
of  different  strengths  for  different  bacteria  is  comparatively  new.  For 
instance,  the  hypertonic  solutions  have  a  very  pronounced  effect  upon 
the  pyocyaneus  and  greatly  stimulate  the  action  of  the  white  blood 
corpuscles.  The  isotonic  act  best  in  the  streptococcus  infection  and 
also  show  a  tendency  to  dilute  the  lymph,  and  in  this  way  make  it 
possible  for  the  white  blood  corpuscles  to  enter  the  wound  and  carry 
on  their  work.  It  is  known  that  they  are  the  most  deadly  enemy  of  the 
streptococcus,  while  this  organism  does  very  well  in  lymph. 


THE  IMMEDIATE  TREATMENT  OF  WAR  INJURIES. 

An  eminent  United  States  army  medical  officer,  after  experience  in 
both  English  and  French  hospitals,  gives  the  following  conclusions : 

"The  first  and  most  important  factor  is  time:  the  patients  must  be 
seen  early,  preferably  in  six  to  eight  hours,  and  certainly  within 
twenty-four.  When  they  cannot  have  adequate  treatment  inside  two 
or  three  days  the  amount  of  gas  infection  and  the  severity  of  it  is 
appalling.  Cases  that  would  have  meant  simply  a  thorough  debride- 
ment, as  the  French,  or  excision,  as  the  British  call  it,  in  the  early 
treatment  require  perhaps  high  amputation  or  may  die,  no  matter 
what  the  treatment,  in  a  few  hours.  A  fulminating  type  of  case  may 
not  last  twenty-four  hours.  In  the  very  early  stages  of  gas  infection 
one  sometimes  finds  only  one  or  a  small  group  of  muscles  involved — 
excise  these  and  the  patients  get  well.  The  signs  are  restlessness; 
pain  that  is  very  characteristic — due  to  the  swelling;  rapid  jump  in 
pulse,  say  120  to  140;  great  swelling;  tenderness  may  or  may  not  have 
crepitation;  thin  grayish  discharge,  with  very  characteristic  sweetish 
odor.  On  opening  the  wound  the  muscle  is  grayish,  non-contractile 
when  pinched  with  forceps,  and  there  is  a  very  little  grayish  discharge. 
Infection  tends  to  run  up  the  muscle.  Excision  of  the  infected  muscles 
or  amputation,  the  stump  being  packed  open  with  magnesium  sul- 
phate or  flavine,  is  the  treatment.  Roughly,  there  are  three  clinical 
types,  the  more  superficial  type  being  not  so  rapid,  with  bronzing 
of  the  skin  and  crepitation.  This  type  is  treated  by  extensive  multiple 
incisions  and  is  relatively  rare.  Second,  there  is  the  massive  gan- 
grene from  swelling  and  occlusion  of  the  circulation  at  an  early  stage. 


672       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

This  requires  amputation.  Then  there  is  the  most  common  type, 
with  infection  of  the  different  muscles,  with  some  shutting  off  of  the 
circulation  from  swelling  and  the  extension  of  the  muscle  involvement, 
determining  the  treatment,  whether  they  can  be  excised  or  if  both 
the  more  superficial  as  well  as  deep  muscles  involved.  Amputation 
is  necessary  for  these  cases.  There  is  a  serum  that  has  yielded  good 
results  experimentally,  but  in  the  few  cases  in  which  I  have  seen  it 
tried  I  cannot  say  definitely  that  it  has  been  of  value.  It  is  for  the 
B.  welshii  type,  I  believe.  All  these  cases  can  practically  be  prevented 
if  the  patients  are  treated  early  enough  by  excision.  If  there  is  a 
wound  of  entrance  and  of  exit  they  are  not  .T-rayed  but  penetrating 
wounds,  are  screened  and  the  location  and  depth  mark  placed  by  the 
radiographer  before  they  come  to  the  operating  room.  It  is  a  good 
plan  always  to  find  out  in  what  position  the  patient  was  when  he  was 
shot,  as  it  helps  to  locate  the  foreign  body  and  to  follow  down  the 
tract.  In  the  operating  room  the  patients  are  shaved,  washed  and 
painted  with  2  per  cent,  picric  acid  in  methylated  spirits,  the  wound  is 
excised,  the  tract  is  widely  laid  open  and  all  injured  muscle,  bits  of 
free  bone,  foreign  bodies,  and  areas  of  hemorrhage  removed  with 
scissors  and  forceps  or  with  the  knife.  Nerves  and  sometimes  ten- 
dons are  sutured,  but  so  far  as  possible,  catgut,  etc.,  are  avoided,  so 
as  not  to  introduce  foreign  material  into  the  wound.  All  joints  are 
treated  in  this  manner  and  invariably  sewed  up  tight.  Sometimes 
'Bip.'  (bismuth,  iodoform,  paraffin)  is  introduced  before  closiue.  In 
other  cases  than  joints  primary  suture  is  only  done  when  the  patient 
can  be  kept  for  five  to  ten  days,  as  transport  has  been  found  very 
detrimental  to  good  results,  probably  from  traumatism  and  the  exu- 
date that  is  caused.  Usually  the  wound  is  packed  wide  open  with 
flavin.  This  can  be  left  in  for  from  two  to  four  days,  is  non-irritating 
and  leaves  a  healthy  field  suitable  for  delayed  primary  suture,  this 
being  done  at  the  base  in  three  to  six  days,  the  patient  being  evacu- 
ated as  soon  as  possible  after  the  primary  operation.  If  flavine  is 
used  as  a  dressing  for  more  than  five  days  granulations  become  slug- 
gish. Results  in  treatment  of  compound  fractures  by  primary  suture 
are  good,  but  the  patient  cannot  be  moved.  Only  remove  free  bone 
fragments;  all  that  are  attached  by  periosteum  should  be  allowed 
to  remain.  The  commonest  failures  are  due  to  a  hemolytic  strepto- 
coccus. In  these  cases  there  is '  a  thin  grayish  discharge  and  the 
edges  of  the  wound  appear  to  melt  away.  One  thing  is  pretty  definite 
in  regard  to  war  wounds:  the  whole  secret  is  cleaning  the  wounds 
mechanically  by  excision  of  the  wound  and  traumatized  tissue,  thus 
removing  the  infection  before  it  has  a  chance  to  spread.  Time  is  the 
factor.  The  French  are  keen  on  the  use  of  ether  in  woimds  and  the 
British  *Bip.'  or  flavine,  but  neither  will  keep  a  wound  from  becoming 
infected  if  it  is  not  freely  opened  up,  cleaned  out  and  foreign  bodies 
removed." 
The  record  of  wounds  in  the  base  hospital  work  in  Russia,  reported 


PRINCIPLES  OF  PLASTIC  AND  ORAL  SURGERY  673 

by  Major  H.  H.  Snively/  N.  G.  Ohio,  late  director-in-chief  of  the 
American  Red  Cross  in  Russia,  shows  a  proportion  of  fractures  of  the 
jaws  to  other  fractures: 

RELATIVE  FREQUENCY  OF  JAW  FRACTURES  IN  WAR  WOUNDS. 

Grand  total. 

Cranium 78 

Face .  .114 

Mandible 205 

Hyoid 6 

Vertebra 19 

Ribs 78 

Pelvis       ...            28 

Cla^^cle 60 

Scapula 68 

Humerus 235 

Ulna 176 

Radius 153 

Carpals 64 

Metacarpals 77 

Phalanges 160 

Femur 163 

Patella ....  26 

Tibia 123 

Fibula 70 

Tarsals 38 

Metatarsals 26 

Phalanges 31 

Total 1998 


THE  PRINCIPLES  OF  PLASTIC  AND  ORAL  SURGERY  AS  APPLIED 
TO  WAR  INJURIES. 

The  essential  features  to  be  considered  in  the  treatment  of  extensive 
war  wounds  of  the  face  and  jaws  are: 

1.  Antiseptic  precautions  to  provide  the  utmost  preparation  for 
healing  which  will  facilitate  in  the  highest  possible  degree  future  recon- 
struction, with  a  view  to  the  restoration  of  both  functional  and  cosmetic 
effects. 

2.  The  correction  of  fractured  and  displaced  bone  structures.  For 
this  purpose  any  of  the  splints  and  appliances  shown  in  Figs.  172,  174 
to  189,  218  to  ^224,  235  and  236,  illustrating  the  treatment  of  frac- 
tured and  resected  jaws,  might  be  applied.  In  addition  to  these  it  is 
interesting  to  note  the  infinite  number  of  ingenious  appliances  that  have 
been  successfully  used  in  the  hospitals  of  France,  England,  Germany 
and  Austria  during  this  war,  as  presented  in  the  illustrations  of  this 
chapter. 

3.  The  use  of  artificial  supports  to  hold  the  soft  parts  in  such  position 
when  plastic  operations  are  performed  that  the  healing  may  be  of  such 
character  as  to  give  the  best  possible  form.  For  this  purpose  various 
substances  have  been  used.     INIost   commonly,  however,  \ailcanitej 

1  The  Military  Surgeon,  xxx\'iii,  634. 
43 


674       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

as  shown  in  Fig.  554,  tin  as  illustrated  in  Fig.  556,  and  modelling 
compound,  as  demonstrated  by  Dr.  Joseph  C.  Beck,  of  Chicago,  111., 
and  illustrated  in  Figs.  509  to  524.    The  author  has  found  gutta-percha 


Fig.  509. — Incision  for  resection  of  the 
upper  jaw.  From  outer  canthus  to  side  of 
nose,  down  and  under  nose  to  median  line 
through  hard  and  soft  palate. 


Fig.  510. — Temporary  resection  of  the 
upper  jaw.  Chisel  through  zygoma,  intra- 
orbital margin,  nasal  process  of  superior 
maxilla  and  aperture.  Between  central 
incisors  through  hard  palate  everting  mass. 


Fig.  511. — Permanent  resection  of  the 
upper  jaw.  Remove  everted  fragment  of 
maxilla  as  well  as  any  overhanging  por- 
tions, also  posterior  lateral  part. 


Fig.  512. — Cavity  filled  with  gauze,  re- 
tained in  a  sort  of  hammock  fashion. 


very  useful  for  this  purpose,  in  a  considerable  variety  of  cases,  because 
of  the  facility  with  which  it  may  be  molded  to  the  form  of  the  parts 
and  its  complete  freedom  from  irritating  tendencies. 


PRINCIPLES  OF  PLASTIC  AND  ORAL  SURGERY 


675 


4.  Bone-grafting,  which  must  be  resorted  to  when  considerable 
portions  of  bone  have  been  lost  beyond  the  point  from  which  it  might 
be  expected  restoration  could  occur  by  natural  growth  without  grafting 
if  the  parts  were  held  in  position.    That  natural  restoration  is  pos- 


FiG.  513.— Cavity  filled  with  dental 
modelling  compound. 


Fig.  514. — Shape  and  size  of  filling 
mass.  Temporary  support  made  of  den- 
tal compound  to  aid  normal  healing  of 
face. 


Fig.  515. — Wound  closed. 


Fig.  516. — Shows  compound  commi- 
nuted fracture  of  mental  region  of  lower 
jaw,  including  loose  teeth. 


sible  to  a  much  greater  extent  than  is  commonly  recognized  is  shown 
in  Fig.  259,  page  440,  Fig.  291,  page  467,  and  Fig.  526,  page  678.  In 
each  of  these  cases  the  author  removed  almost  all  of  the  mandible  from 
near  the  angle  of  the  jaw  on  one  side  to  the  bicuspid  region  on  the 
other,  and  by  preserving  the  periosteum  and  the  natural  outline  of 


676       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

the  jaw  sufBcient  hard  structure  was  reproduced  to  retain  the  correct 
outHnes  of  their  faces.  The  young  woman  now  wears  a  vulcanite  plate 
in  the  lower  jaw,  with  complete  comfort  over  the  region  from  which 
the  bone  was  removed.    In  the  author's  opinion  many  jaws  have  been 


Fig.  517. — Shows  fragments  adapted  and 
useless  particles  of  bone  removed. 


Fig.  518. — Shows  fragments  ^sdred. 


bone  grafted,  which  if  simply  held  in  proper  position,  with  perfect 
fixation,  would  have  received  sufficient  restoration  without  such  treat- 
ment. A  further  example  of  this  is  sho-v\m  in  the  case  of  the  young 
woman  shoT;\Ti  in  Figs.  525  and  526,  in  which  after  having  false  union 


Fig.  519. — Shows  defect  with  fragments 
removed. 


Fig.  520. — Shows  all  fragments  removed 
and  ca\'ity  filled  with  dental  compoimd. 


in  the  mental  region  of  the  lower  jaw  for  twenty  years,  upon  fixation 
in  the  course  of  a  few  weeks  the  parts  became  quite  firm. 

5.  The  transplantation  flaps  of  tissue  from  other  parts  to  supply 
covering  for  wounds  with  extensive  loss  of  tissue. 


PRINCIPLES  OF  PLASTIC  AND  ORAL  SURGERY 


677 


6.  Orofacial  prosthesis,  or  the  restoration  of  lost  portions  of  the 
face  by  artificial  substitutes  made  from  metal,  \'ulcanite,  wax  or  other 
suitable  substances. 


Fig.  521. — Shows  the  dental  compound  model 
for  subsequent  prosthesis. 


Fig.  522. — Defect  filled  with  clavicle 
transplant  and  wired. 


The  principles  of  bone-grafting  are  now  well  understood,  the  use  of 
metal  plates  such  as  those  devised  by  Sir  Arbuthnot  Lane,  of  London, 
and  the  Sherman  plates  shown  in  Fig.  552  and  modifications  of  these 
fixation  devices  have  been  quite  general  among  surgeons  \\ath  varying 
degrees  of  success. 


Fig.  523. — Shows  teeth  wired  and  held 
in  apposition  with  the  upper  jaw. 


Fig.    524. — Shows   wound    sutured  and 
drainage  tubes  at  the  lowest  part. 


There  are,  however,  certain  special  features  of  this  work  that  relate 
particularly  to  jaw  conditions  which  must  be  provided  for  under  every 


078       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

condition,  when  the  continuity  of  either  jaw  is  lost  by  injury,  whether 
the  cause  be  accident,  surgical  or  gunshot. 

The  immobilization  of  a  divided  mandible  is  sometimes  not  so  easily 
accomplished  as  illustrations  would  often  make  it  appear,  and  without 
it  a  mandibular  bone  graft  has  small  chance  of  accomplishing  the 
desired  result. 


Fig.  525. — Congenital  fibrous  band 
extending  from  the  jaw  to  the  clavicle, 
causing  deformity  shown  and  rendering 
it  impossible  to  hold  the  head  com- 
fortably in  an  upright  position.  The 
divided  jaw  was  fixed  with  a  splint  at- 
tached to  the  teeth. 


Fig.  526  (same  girl  shown  in  Fig.  525). 
— After  correction  of  the  defect  by  a 
transverse  incision  at  a  point  just  above 
the  thyroid  cartilage  through  the  fibrous 
band  and  after  freeing  the  surrounding 
tissue  the  skin  was  drawn  from  the  cen- 
tral portion  of  the  incision  above  and 
below,  upward  and  downward  until  when 
brought  together  the  line  of  incision  was 
perpendicular  instead  of  parallel.  A  slight 
trimming  of  the  skin  at  each  end  of  the 
suture  line  was  necessary  in  order  to 
complete  the  outHne  of  the  neck. 


Infection  from  the  oral  secretions,  if  by  chance  the  wound  for  insertion 
of  the  graft  penetrates  the  buccal  mucous  membrane,  is  also  a  serious 
disadvantage. 

Albee,  whose  methods  of  cutting,  insertion  and  fixation  are  illus- 
trated in  Figs.  531  and  533,  had  devised  methods  to  meet  these  diffi- 


TREATMENT  OF  JAW  FRACTURES  679 

culties,  and  tlirough  his  wide  experience  has  full  realization  of  the 
importance  of  such  considerations. 

In  the  reconstnidion  of  faces  deformed  by  the  more  extensive  gun- 
shot and  other  war  injuries,  the  underlying  conditions  and  effects  are 
precisely  the  same  as  those  encountered  in  the  correction  of  the  lesser 
defects  illustrated  in  Figs.  373  to  410  and  Figs.  433  to  467,  in  which 
congenital  deformities  of  the  lip  and  nose  and  the  exaggeration  of  these 
by  previous  operative  treatment  required  reconstructive  surgical  opera- 
tions for  cosmetic  purposes.  It  is  therefore  important  to  remember 
that  whenever  it  is  possible  to  take  advantage  of  the  elasticity  of  the 
tissues  of  the  face  and  neck  to  extend  them  so  as  to  cover  or  at  least 
partially  cover  a  surface  from  which  the  tissue  may  have  been  lost,  this 
should  be  done.  If  necessary,  step  operations  may  be  continued  until 
the  closure  is  completed  without  transposition  of  tissue  from  another 
part.  The  result  in  the  course  of  time  would  then  be  much  more 
perfect  both  from  the  functional  and  cosmetic  considerations.  If, 
however,  the  defect  is  so  extensive  that  this  is  not  possible  then  the 
transposition  of  a  flap  from  some  adjacent  part  or  from  the  arm  accord- 
ing to  well-known  methods  may  be  necessary.  A  mass  of  tissue  without 
the  possibility  of  muscular  adaptation  to  give  proper  functional 
activity  may  be  helpful  in  miproving  the  appearance  of  the  individual, 
but  in  the  last  analysis  must  nearly  always  be  more  or  less  disappointing. 
It  is  a  grave  question  if  in  many  cases  where  plastic  surgery  is  attempted 
a  prosthetic  appliance  artistically  made  and  adapted  might  not  give  a 
better  appearance  than  the  surgical  result. 


AMERICAN   AMBULANCE  HOSPITAL  METHODS    OF  TREATMENT 
OF  JAW  FRACTURES. 

Dr.  Harvey  Gushing,^  j\I.D.,  Medical  Reserve  Corps,  U.  S.  A. 
(Inactive),  surgeon-in-chief  to  the  Peter  Bent  Brigham  Hospital, 
Boston,  INIass.,  pays  this  tribute  to  the  American  Ambulance  of  Paris: 
"A  practical  example  of  the  value  of  surgical  specialization  in  warfare 
is  afforded  by  the  experience  of  the  American  Ambulance  in  Paris, 
where,  owing  to  the  brilliant  reparative  work  on  patients  with  fractured 
jaws,  inaugurated  by  Dr.  Hayes  and  his  colleagues,  of  all  inmates 
some  20  per  cent,  were  victims  of  wounds  of  this  type.  A  general 
surgeon  can  set  a  broken  jaw,  but  as  a  rule  just  badly  enough  so  that 
the  teeth  are  not  in  exact  alignment,  and  a  soldier  who  cannot  masticate 
coarse  food  is  about  as  inefi'ective  as  one  who  has  crippled  feet.  If 
Napoleon's  army  marched  on  its  belly,  Joffre's  holds  on  with  its  teeth, 
and  only  experts  can  make  50  per  cent,  of  lacerated  faces  and  jaws 
capable  again  of  army  crusts." 

Dr.  Benjamin  Jablons,^  pathologist  of  the  American  Ambulance 

1  The  Militarj-  Surgeon,  xxx\-iii.  605. 
^  New  York  Med.  Jour.,  civ^,  552. 


680       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

of  Paris,  gives  the  following  summary:  The  cases  treated  may  be 
divided  into  two  general  classes.  First,  gunshot  injuries;  a  large 
majority  of  which  have  involved  compound  and  multiple  fractures, 
and,  second,  gunshot  wounds  of  the  face  involving  the  maxillae,  and 
requiring  the  intervention  of  dental  surgery.  This  latter  class  has 
greatly  increased  in  number,  owing  to  the  unique  facilities  of  the 
American  Ambulance  for  their  treatment.  The  number  of  patients 
received  during  the  year  ending  August  31  has  been  2622,  of  whom 
1968  have  been  discharged,  cured,  or  improved;  117  have  died  and 
536  remained  under  treatment.  The  death-rate  has  been  4.46  per  cent. 
Dr.  Francis  Wilson,  of  Paris,  formerly  Chief  of  the  Dental  Service  of  the 
American  Ambulance  Hospital  (B.  at  Juilly),  Paris,  with  his  associates 
Drs.  Hayes  and  W.  Davenport  (at  Neuilly)  and  others,  during  three 
years  of  faithful  service,  took  personal  charge  of  an  enormous  number 
of  cases  of  fracture  of  the  jaws.  The  restoration  work  accomplished 
by  these  men  and  other  Americans  scattered  throughout  the  hospitals 
of  Europe  will  long  continue  to  be  a  matter  of  national  as  well  as 
professional  pride.  Dr.  Wilson  writes:  "As  Juilly  was  more  a  front 
line,  we  were  often  obliged  to  evacuate  our  wounded  before  they  were 
cured.  For  example,  in  September,  1915,  I  had  52  cases  of  fracture  of 
the  maxillte  enter  the  hospital  in  one  afternoon;  of  these  I  saw  only  2 
completely  cured — all  the  others  were  "sent  to  hospitals  away  from 
the  war  zone  some  ten  days  later.  Among  these  52  cases  were  some 
of  the  .worst  that  have  ever  come  under  my  observation.  In  fact,  it 
would  be  difficult  to  imagine  how  many  of  these  could  have  been 
worse.  One  poor  fellow  had  the  entire  face  below  the  eyes  blown  off, 
nothing  remaining  of  the  inferior  maxilla.  Among  the  simpler  cases  a 
great  many  multiple  fractures,  particularly  of  the  lower  jaw,  some 
fractured  in  five,  six,  seven,  or  eight  places.  My  work  was  to  wire 
these  together  so  the  man  could  eat  soft  food  besides  being  more  com- 
fortable. The  mouths  were  washed  out  with  a  mild  antiseptic  or 
normal  salt  solution  as  many  as  six  or  eight  times  a  day.  When  the 
inflammation  subsided  sufficiently,  we  took  impressions,  extracted 
useless  roots  and  made  cast  splints  which  were  cemented  to  place.  I 
might  mention  that  very  often  portions  of  the  inferior  maxilla  would 
be  found  missing  ranging  in  size  from  slight  splits  to  even  half  or  all 
of  the  jaw.  We  find  with  a  good  interdental  splint  that  nature  fur- 
nishes bone  substance  in  many  of  the  cases. 

A  case  in  mind  brought  in  February,  1916,  was  wounded  in  the 
lower  maxilla  in  the  region  of  the  right  canine  by  a  splinter  of  shell. 
The  lower  right  lateral  and  central  incisors  were  carried  aMay  together 
with  a  portion  of  maxilla  the  same  width  as  the  combined  width  of 
the  teeth  above  mentioned.  I  put  on  a  splint  allowing  for  the  space 
between  cuspid  and  left  central  and  from  three  weeks  to  a  month  after 
he  had  an  osseous  union  of  the  two  portions. 

Examples  of  the  conditions  under  wdiich  first-aid  treatment  must  be 


TREATMENT  OF  JAW  FRACTURES 


681 


rendered  in  war  injuries  of  the  jaws  upon  the  success  of  which  later 
reconstructive  o])erations  must  depend  are  shown  in  Figs.  527  to  530. 


Fig.  527  Fig.  52S 

Figs.  527  and  528. — Loss  of  the  entire  right  side  at  the  superior  maxilla  destroyed  by  a 

piece  of  shell. 

These  cases  were  selected  from  among  those  treated  by  Dr.  Francis 
Wilson,  of  Paris,  in  Neuilly,  at  the  front  line  hospital  in  Juilly.  (Pho- 
tographs by  ]Mr.  Frank  Burky.) 


Fig.  529. — Shell  wound  with  loss  of  the 
entire  mandible  anterior  to  the  ramus. 


Fig.  530. — Illustrates  a  case  in  which 
hemorrhage  occurred  three  weeks  after  the 
patient  entered  the  hospital,  requiring  the 
ligation  of  the  right  external  carotid  arterj', 
and  eighteen  days  later  when  the  same 
operation  was  required  on  the  left  external 
carotid  because  of  the  anastomosis  from 
the  left  to  the  right  side.  (Photographs 
by  Burkj-.) 


The  wonderful  work  accomplished  by  the  Association  of  Surgeons 
and  Dentists  in  the  treatment  of  these  cases  in  Xeuilly  is  illustrated 
in  Figs.  546  to  553. 


682      TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

OPERATION  IN  INFECTED  FRACTURES. 

Joseph  Rilus  Eastman,  M.D.,  F.A.C.S.,  Indianapolis,  Indiana, 
formerly  chief  surgeon,  Reserve  Hospital  No.  8,  Vienna,  Austria, 
has  written  especially  for  this  chapter  these  conclusions  from  his 
war  experiences: 

It  need  hardly  be  said  that  infected  gunshot  fractures  do  not  tol- 
erate open  operative  interference.  Practically  all  gunshot  fractures 
are  infected,  therefore  the  field  of  operative  surgery  in  war  fractures  is 
relatively  small. 


Fig.  531. — Diagram  of  a  fractured  lower  jaw  illustrating  the  inlay  bone  graft  in 
place  imbedded  in  the  gutter  cut  in  both  fragments  by  the  twin  motor  saws.  The 
graft  has  been  procured  from  the  antero-internal  surface  of  the  tibia  cut  by  the  twin 
motor  saws  adjusted  at  the  same  distance  apart  as  when  cutting  the  gutter  in  the  jaw 
fragments.  Note  the  drill  holes  and  that  the  graft  is  fixed  in  place  by  kangaroo  sutures. 
(Albee.) 


In  the  case  of  gunshot  fracture  of  the  lower  jaw,  the  experience  of 
this  war  has  proved  that  primary  bone  suture  or  wiring  is  to  no  good 
purpose.  It  has  been  shown  in  these  cases  that  primary  bone  suture 
is  rarely  effective,  that  primary  healing  never  occurs,  and  that  sup- 
puration and  sequestrum  formation  always  follow.  In  other  words, 
the  primary  bone  suture  in  jaw  fractures  does  only  harm  and  no  good. 

The  experience  of  the  present  war  has  demonstrated  that  for  weeks 
after  apparently  complete  healing  of  gunshot  fracture  wounds,  the 
infection  lurks  in  bone  and  soft  tissues  about  the  site  of  fracture, 
making   any   open   operative   procedure   a    dangerous   undertaking. 


OPERATION  IN  INFECTED  FRACTURES 


683 


Fractures  plated  two  months  after  the  disappearance  of  every  dis- 
coverable vestige  of  infection  or  inflammation  have  reacted  with 
what  bore  every  evidence  of  a  recrudescence  of  the  old  infection. 
The  .T-rays  in  these  cases  revealed  no  signs  of  inflammation  and  none 
were  found  during  the  operation  itself. 

A  gunshot  fracture  healed,  but  harboring  a  dormant  infection, 
could  hardly  be  subjected  justly  to  operation,  especially  a  plastic 
operation,  except  upon  the  erroneous  assumption  that  the  infection 
had  entirely  disappeared.  As  it  is  almost  impossible  to  learn  before 
or  even  during  operation  of  the  presence  of  infection  in  healed  cases 
and  in  so  much  as  the  infection  often  persists  for  months  with  no 
manifestations  whatever,  it  follows  that  open  operation  in  healed 
gunshot  fractures  should  not  be  undertaken  without  due  sense  of 
the  dangers  of  lurking  infection.  The  manipulation  required  to  com- 
plete a  bone  plastic  operation  without  much  doubt  stirred  up  latent 


Fig.  532. — Diagram  showing  a  cross-section  of  the  inlay  bone  graft  implanted  for 
a  fracture  of  the  lower  jaw  and  showing  the  method  of  securing  the  graft  in  position 
by  the  kangaroo-tendon  suture  passed  through  the  drill  holes  and  over  the  graft,  holding 
it  securely  in  position.     (Albee.) 

infections  in  several  of  our  cases.  Fortunately,  frequent  continuous 
irrigation  with  Dakin's  solution  permitted  good  approximation  of  the 
fragments  and  sufficed  to  control  the  infection,  which  was  from  the 
beginning  of  its  flare-up  in  an  attenuated  form,  the  discharge  being 
made  up  largely  of  lymph  and  containing  relatively  few  pyogenic 
bacteria  and  pus  cells.  Such  experiences  teach  a  lesson  which  although 
in  a  sense  generally  understood,  is  perhaps  not  sufficiently  appreciated, 
i.  e.,  that  open  operation  in  gunshot  fracture  with  deformity  is  not 
indicated  before  two  months  at  the  very  least  have  elapsed  after  the 
disappearance  of  every  sign  of  infection.  Then  the  operation  should 
take  the  simplest  form  possible  under  the  circumstances,  which  means 
simple  osteotomy  with  splinting  in  a  large  percentage  of  cases. 

In  completely  healed  infection-free  gunshot  fractures,  the  autog- 
enous bone  graft  represents  the  ideal  method  of  holding  fragments 
in  alignment  and  coaptation.  If  an  autogenous  graft  cannot  be 
obtained  the  bones  of  a  dog  or  those  of  a  calf  may  of  course  be  utilized, 


684       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 


but  far  greater  safety  and  greater  convenience  consist  in  using  bone 
pencils  cut  from  the  edge  of  the  tibia  or  from  some  other  bone  easily 
accessible.  Judging  from  a  limited  experience  in  the  use  of  autogenous 
grafts  for  the  retention  of  fragments  in  good  position  it  has  appeared 
that  such  grafts  cause  less  irritation  and  have  less  tendency  to  provoke 
recurrence  of  infection  than  do  plates  or  other  metal  devices. 


Fig.  533. — Diagram  of  a  fractured  lower  jaw  so  badly  shattered  as  to  leave  a  gap 
where  a  proper  position  of  the  remaining  fragments  is  maintained.  This  gap  can  be 
satisfactorily  spanned  and  the  fragments  securely  united  through  the  inlay  method 
with  a  graft  and  gutter  produced  by  the  twin  motor  saws  adjusted  at  the  same  dis- 
tance apart,  producing  an  accurate  fit  of  the  graft  which  is  held  in  position  by  kan- 
garoo-tendon sutures  passed  through  drill  holes  in  jaw  fragments.  This  is  a  frequent 
condition  in  the  present  war,  resulting  from  the  trench  warfare.     (Albee.) 

Whether  the  transplanted  bone  heals  in  as  a  foreign  body  and  later 
disappears  by  resorption,  as  held  by  Oilier,  Gebhardt,  and  Ullmann, 
or  whether  a  part  continues  to  live  as  stated  by  Marchand  and 
Axhausen,  is  an  old  question  of  no  great  importance  in  this  connec- 
tion. The  important  clinical  fact  for  us  is  that  if  laid  in  correctly 
the  graft  unites  in  some  manner  with  the  surrounding  bone  and 
serves  as  a  support.  As  advised  by  Shaffer  no  more  bone  should  be 
transplanted  than  is  absolutely  necessary,  and  care  of  course  should 
be  taken  that  the  osteoblastic  periosteimi  is  intact  along  one  side 
or  margin  of  the  peg  or  intramedullary  graft.  Moreover,  the  grafts 
should  be  so  cut  as  to  contain  as  little  compact  bone  as  possible  for 
the  generally  admitted  reason  that  compact  bone  after  transplanta- 
tion requires  a  longer  time  for  resorption  than  does  spongy  bone, 
the  porosity  of  which  allows  the  ingrowth  of  vascular  connective 


OPERATION  IN  INFECTED  FRACTURES 


685 


tissue  and  lime-bearing  osseous  trabeculae.  Care  should  also  be 
taken  that  no  blood  or  devitalized  tissue  is  interposed  between  the 
intramedullary  pencil  and  the  endostium  of  the  fragments,  since 
the  resorption  of  such  foreign  matter  must  of  course  precede  the 
ingrowth  of  vascular  connective  tissue  into  the  graft. 

It  is  probable  that  in  our  cases  the  intramedullary  pencil  serves 
merely  as  a  support.  The  dowel  graft,  however,  if  inlaid  so  that  the 
periosteum  of  the  graft  lies  in  contact  with  the  periosteum  of  the 
fracture  fragment  and  with  the  other  bone  layers  in  normal  relation 
actually  grows  into  the  surrounding  bone.  In  the  case  of  the  intra- 
medullary pencil  it  is  practically  impossible  to  bring  the  periosteum 
of  the  graft  into  contact  with  that  of  the  fracture  fragment.     How- 


FiG.  534. — Illustrates  bone  graft  in  place  with  fixation  of  the  jaw  fragments  by  a 
cap  splint  cemented  to  the  teeth  as  described  by  Mr.  Montagu  Hopson,  L.D.S.,  R.C.S., 
dental  surgeon  to  Guy's  Hospital;  consulting  dental  surgeon  to  the  War  Hospitals  in 
the  London  Command  in  the  War  Supplement  of  the  British  Dental  Journal.  In  this 
case  a  segment  of  the  sixth  rib  was  made  to  fit  in  the  notches  cut  in  each  exposed  end  of 
the  fractured  mandible.  This  splint  has  since  been  removed  and  an  artificial  denture 
inserted  with  complete  success. 


ever,  as  above  stated,  the  matter  of  chief  importance  is  that  the 
autogenous  intramedullary  splint  provides  good  support  during 
the  process  of  union  of  the  fragments,  and  this  it  seems  to  do  much 
better  than  a  dowel  graft  insofar  as  our  cases  were  able  to  illustrate. 
Though  the  dowel  graft  with  proper  apposition  of  histological  layers 
grows  in,  and  the  intramedullary  autogenous  bone  splint  remains  in 
most  instances  as  a  foreign  body,  nevertheless,  in  fractures  with 
obstinate  tendency  to  angulation,  the  bone  peg  in  the  medulla  gives 
the  best  possible  support,  the  thing  most  desired. 

In  view  of  the  danger  of  arousing  latent  infections  in  healed  gun- 
shot fractures  with  shortening,  Finisterer,  of  Vienna,  has  advised 
that  all  open  operations  made  during  the  first  year  after  healing  of  the 
wound  should  be  made  at  the  site  of  the  fracture  but  remote  from  it. 


686       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

In  treating  infected  wounds  the  following  resources  are  employed 
in  the  American  Hospital  in  Vienna: 


frrT') 


%A 


Fig.  535. — Application  of  the  motor-saw  in  operation  for  closing  gap  in  mandible 
produced  by  gunshot  wound.     (After  Gallic  and  Robertson.') 


Fig.  536. — Insertion  of  half  of  spHt  rim  with  smooth  side  toward  the  mouth  ca-\aty. 
(After  Gallic  and  Robertson.) 


•  Transplantation  of  Bone.     By  W.  E.  Gallic,   M.D.,  and  D.  E.  Robertson,   M.D. 
Toronto,  Journal  of  the  American  Medical  Association,  April  20,  1918,  p.  1134. 


OPERATION  IN  INFECTED  FRACTURES 


687 


1.  Removal  of  infected  bits  of  clothing  or  other  infected  foreign 
matter. 

2.  Wide  incision  and  drainage. 

3.  Immobilization. 


'A 


'"•"  II  III    "  ■   -  '^ 


Fig.  537. — Completion  of  operation  by  the  placing  of  the  other  half  of  the  rib  in 
contact  ■with  the  first  half  between  the  ends  of  the  fragments  and  by  the  fastening  of 
all  in  place  with  kangaroo  tendon.     (After  Gallie  and  Robertson.) 

4.  Continuous  irrigation  by  the  drop  method  with  Dakin's  solution 
of  sodium  h\'pochlorite,  or  continuous  immersion  in  hot  antiseptic 
solutions,  as  acetate  of  aluminum. 

5,  Stimulation  of  l\Tnph  drainage  with  Wright's  solution  of  sodium* 
citrate  1  part,  sodium  chloride  4  parts,  and  water  95  parts. 


Fig.  538. — Soldier  on  whose  jaw  operation  was  performed;  range  of  motion  of  jaw 
normal.     (After  Galhe  and  Robertson.) 

6.  Regular  and  prolonged  daily  exposure  to  the  rays  of  the  sun. 

7.  Continuous  exposure  of  all  wounds  to  the  air  without  dressings 
whenever  possible  to  avoid  foreign-body  reaction. 

We  have  not  made  use  of  Clumsky's  solution  of  camphor  and 
phenol. 


688       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

Small,  superficial,  slightly  infected  tangential  wounds  are  rinsed 
with  normal  salt  solution  or  hydrogen  peroxide  and  covered  with 
Peru  balsam,  or  Mikulicz's  salve. 

Of  these  agents  those  which  have  proved  of  greatest  value  are : 

(a)  Solar  therapy. 

(6)  Open  treatment  without  dressings  to  promote  drying  and  to 
prevent  foreign-body  reaction. 

(c)  Continuous  irrigation  with  sodium  hypochlorite  solution,  com- 
posed of  dry  sodium  carbonate,  chlorinated  lime,  boric  acid,  and  tap 
water. 

Naturally  the  method  of  treatment  and  the  agents  to  be  employed 
in  each  case  are  determined  by  the  nature  of  the  infection  and  the 
character  of  the  wound.  For  oiu-  own  convenience  we  have  made  the 
following  simple  classification: 

GUNSHOT   WOUNDS    AND    FRACTURES    OF    FACE    AND    JAWS.i 

The  leading  features  to  remember  are  the  extraordinarily  rapid  union 
of  wounds  in  this  region  and  the  importance  of  not  uniting  the  wound  in 
the  soft  parts  over  shattered  bone  and  pieces  of  impacted  metal.  This  is 
especially  likely  to  occur  in  the  antrum  and  nares.  The  bone  destruc- 
tion may  be  terrible.  In  one  young  soldier  I  removed  the  upper  jaw, 
half  the  lower  jaw,  the  palate,  part  of  the  ethmoid,  and  the  pterygoid 
plates.  The  soft  parts  were  united  over  the  huge  gap,  and  the  resulting 
deformity  was  far  less  than  might  have  been  expected.  It  is  important 
to  preserve  the  orbital  plate  of  the  maxilla,  or,  if  this  is  impossible, 
to  maintain  intact  the  periosteum  and  suspensory  ligament  of  the  eye- 
ball, or  the  latter  gets  displaced  downward.  In  the  "rush"  of  early 
cases  I  had  to  treat  some  bad  fractures  of  the  jaw  without  any  special 
apparatus.  I  had  recourse  to  the  old  molded  splint  of  gutta-percha 
and  jaw  bandage  which  I  had  not  applied  for  many  years.  All  loose 
fragments  were  removed  with  forceps,  and  Mr.  Acland  gave  his  aid 
for  the  loose  and  injured  teeth.  The  results  in  these  cases  were  excellent 
and  an  indication  of  what  can  be  done  with  very  simple  measures  in 
very  difficult  cases.  In  fractures  of  the  jaw  extensive  comminution  is 
very  frequent.  I  think  it  well  to  expose  the  parts  by  an  incision  along 
the  inferior  border  and  remove  all  the  fragments  of  shattered  bone. 
This  is  very  important,  or  after-suppuration  and  obstinate  sinuses  are 
sure  to  persist.  Pus  is  very  apt  to  burrow  down  the  neck  under  the 
cervical  fascia,  and  I  think  it  well  to  drain  through  the  submaxillary 
incision.  In  past  days  I  have  drilled  and  wired  the  bones,  but  I  am 
not  sure  the  results  were  better  than  when  simply  treated  by  a  splint. 
In  these  cases,  however,  the  aid  and  skilful  appliances  of  the  dental 
surgeon  and  mechanism  are  very  essential,  and  molded  metal  or  wire 
splints  very  advantageous.     In  all  instances  the  mouth  should  be 

lA.  Marmaduke  Shield,  M.B.,  F.R.C.S.:     Injuries  of  War,  Lancet,  p.  968. 


GUNSHOT  WOUNDS  AND  FRACTURES  OF  FACE  AND  JAWS    G89 

constantly  washed  out  with  an  antiseptic  lotion.  Permanent  facial 
paralysis  is  often  found  in  wounds  of  the  face,  and  is  very  unsightly. 
When  the  soft  parts  are  extensively  blown  away  the  most  hideous  and 
distressing  deformities  ensue.  What  plastic  surgery  cannot  effect 
must  be  remedied  by  skin-colored  masks.  These  can  often  be  advan- 
tageously supported  on  a  spectacle  frame  (Figs.  569  and  570). 


Fig.  539. — Emergency  splint  designed  by  Col.  Vilray  P.  Blair  and  adopted  by  the 
U.  S.  Army.     (Courtesy  of  the  Detroit  Dental  Manufacturing  Company.) 

•  Figs.  539  and  540  illustrate  an  adjustable  gunning  or  open  bite  splint 
for  emergency  treatment  of  fracture  of  either  jaw.  This  splint  was 
designed  for  and  adopted  by  the  United  States  Army.  It  is  intended 
to  be  used  for  temporary  treatment,  to  fix  fractured  jaws  at  the  earliest 
possible  moment,  and  to  give  support  until  the  patient  may  be  trans- 
ported back  to  a  base  hospital.  Before  being  bent  for  use  it  is  a  flat 
thin  piece  of  metal,  and  therefore  easily  carried. 


Fin.  540. — A  splint  bent  to  the  required  form  and  filled  with  modelling  compound  and 
ready  for  insertion.    (Courtesy  of  the  Detroit  Dental  Manufacturing  Company.) 

Directions  for  Use. — Bending. — -The  pillars  are  to  be  bent  down, 
and  the  splint  to  the  form  shown  in  Fig.  540.  To  do  this  one  tray  is 
laid  on  a  flat  surface,  with  the  posterior  ends  of  the  tray  corresponding 
exactly  to  the  edge  of  the  block  and  the  splint  bent  to  an  angle  of  1.37 
degrees  (Fig.  539).  The  other  tray  is  then  placed  on  the  block  and  the 
44 


690       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

bending  continued  to  90  degrees.  The  bending  is  completed  in  the 
hand. 

Adjustment. — The  splint  is  then  placed  in  the  mouth  to  determine 
if  further  adjustments  are  needed.  The  arch  of  the  trays  may  be 
compressed  or  expanded,- or  any  part  of  either  wall  bent  or  trimmed 
away. 

Amplication. — Both  trays  are  filled  with  modelling  composition, 
made  very  soft  either  in  hot  water  or  over  a  flame.  The  splint  is  placed 
in  the  mouth  and  the  teeth  of  the  uninjured  or  least  shattered  jaw 
are  pressed  deeply  into  the  modelling  composition.  The  remaining 
fragments  of  the  injured  jaw  are  assembled  into  the  best  obtainable 
position  and  the  teeth  of  this  arch  are  also  forced  into  the  composition 
of  the  other  tray.  If  necessary  the  splint  may  be  removed  and  reheated. 
Replacing  it,  the  composition  is  pressed  about  the  crowns  of  the  teeth. 
Dressings  and  a  chin  bandage,  preferably  elastic,  are  applied.  A  chin 
cup  of  modelling  composition  applied  over  light  dressings  under  the 
bandage  will  add  to  stability.  If  it  is  desirable,  the  anterior  ends  of 
the  two  trays  may  be  anchored  together  by  a  wire  ligature. 

Drainage  and  Repair  of  Soft  Parts. — If  possible,  at  the  time  the  splint 
is  inserted,  dependent  external  drainage  should  be  established  at  the 
lines  of  open  fractures.  If  wounds  of  the  cheek  or  lips  are  immediately 
sutured,  the  splint  may  be  retained  until  the  facial  wound  heals 
sufficiently  to  allow  of  its  removal. 

The  following  interesting  cases  are  described  by  Major  G.  E.  Meyer, 
D.D.S.,  R.A.M.C,  Oral  Surgeon  of  the  Twenty-third  General  Hospital, 
British  Expeditionary  Force,  France: 

Sergeant  James  Brown,  Regiment  No.  8336,  Unit  1,  York  Lancers, 
Service  ten  years.     Single,  aged  twenty-seven  years. 

Place  of  Action. — Near  Verlines,  about  2  p.m.,  October  1,  1915. 

Injury  or  Illness. — Compound  fracture  of  lower  maxilla.  Mandible 
blown  away  from  right  lateral  to  about  one-half  inch  above  the  angle 
of  the  jaw  and  the  whole  face,  including  part  of  the  tongue.  The  part 
missing  on  face  extended  from  center  of  chin  down  to  lower  border  of 
neck,  back  to  ear,  and  almost  up  to  nose. 

Immediate  Symptoms. — Profuse  hemorrhage;  no  pain;  first  aid  by 
stretcher-bearers.  Tetanus  antitoxin  administered  at  first  dressing 
station.  When  patient  arrived  his  face  wound  was  in  a  horrible  con- 
dition; patient  running  a  temperature  of  103°;  much  gangrenous 
tissue.    Fig.  541  shows  when  patient  entered  hospital. 

Treatment  and  Operation. — Cut  away  gangrenous  tissue  and  dressed 
with  a  solution  of  eusol,  diluted  two-thirds,  and  irrigated.  After  ten 
days'  treatment  wound  began  to  granulate  in  nicely.  Patient  had  to 
be  fed  with  tube.  Wound  irrigated  every  four  hours  with  1  to  10,000 
solution  of  potassium  permanganate. 

November  1,  1915.  Removed  piece  of  necrosed  bone  one-half  inch 
square.  For  the  upper  and  lower  teeth  on  the  left  side  German  silver 
plates  were  swaged,  covered  with  silver  solder  and  a  wire  soldered  to 


GUNSHOT  WOUNDS  AND  FRACTURES  OF  FACE  AND  JAWS    691 

the  buccal  surface  with  several  loops.  On  the  buccal  surface  of  the 
lower  plate  a  heavy  piece  of  German-silver  plate  was  soldered  which 
glided  on  surface  of  upper  plate  when  patient  closed  jaw,  throwing  jaw 


r^ 

•^ 

Tl^ 

'\ 

Fig.  541. — Condition  when  entering 
hospital. 


Fig.  542. — After  six  months  just 
after  bone  graft  was  placed. 


over  to  left  in  its  normal  position.  The  first  plastic  operation  was 
performed  three  months  later.  The  piece  of  the  mandible  lost  was 
replaced  by  a  graft  from  the  tibia.  A  small  vulcanite  splint  was  made 
to  fit  between  swaged  upper  and  lower  plates  which  were  laced  together 


Fig.  543 


through  loops  that  were  made  on  the  buccal   surfaces,  holding  the 
patient's  jaw  open  about  one-half  inch  and  immovable. 


692       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

Private  L.  P.  (Fig.  543).     Aged  twenty  years. 

Injvry  or  Illness. — Compound  fracture  of  the  lower  jaw  and  shrapnel 
wound  in  right  arm. 

Present  'Findings. — Lower  jaw  fractured  between  the  cuspid  and 
bicuspid.    Four  lower  central  incisors  and  jaw-bone  between  cuspids 


Fig.  514 


completely  shot  away.  Bullet  passed  do-^ii  and  made  its  exit  two 
inches  below  the  angle  of  right  jaw  on  neck,  making  an  opening  on 
neck  three^^inches  in  diameter. 


Fig.  545. — After  four  months. 


Doctor's  Report. — The  patient  coughed  severely  and  expectorated 
a  copious  mucopurulent  secretion.  This  was  never  blood-tinged. 
It  was  thought  at  the  time  that  the  patient  had  an  inspiration  lobar 


GUNSHOT  irOL'.VD.S  AXD  FRACTURES  OF  FACE  AXD  JA]yS     G93 


Fig.  546. — Case  of  Dr.  C.  W.  Bouchet, 
Dr.  C.  J.  Koenig,  and  Dr.  W.  S.  Daven- 
port. Shrapnel  wound  with  fracture  of 
the  maxilla  invoh-ing  the  septum  of  the 
nose  and  a  loss  of  the  right  half  of  the 
upper  lip.     (Dental  Cosmos.) 


Fig.  547. — Same  case  as  shown  in  Fig. 
546,  with  prosthetic  restoration  of  teeth 
and  jaw.     (Dental  Cosmos.) 


Fig.  548. — Same  case  as  shown  in  Figs. 
546  and  547,  after  plastic  operation  to 
restore  lip  and  nose.     (Dental  Cosmos.) 


Fig.  549. — Same  case  as  in  Figs.  544, 
547  and  548,  showing  the  final  result  of 
both  plastic  and  prosthetic  restoration. 
(Dental  Cosmos.) 


694       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

pneumonia.  The  wound  was  heavily  infected,  but  discharged.  A 
bullet  entered  his  open  mouth  and  passed  through  the  neck,  carrying 
with  it  that  part  of  the  mandible  between  the  cuspids. 


Fig.  550. — Case  reported  by  Dr.  R.  B. 
Greenough,  surgeon,  and  Dr.  W.  S.  Dav- 
enport, dentist.  Bullet  entered  the  right 
cheek  and  tore  away  two  bicuspid  and  the 
left  first  molar  teeth  and  other  teeth,  and 
fractured  the  mandible.  The  splints  are 
in  place.     (Dental  Cosmos.) 


Fig.  551. — Splints  used  in  the  case  shown 
in  Fig.  550.     (Dental  Cosmos.) 


The  a--ray  (Fig.  544)  shows  the  splint  applied  to  hold  the  two  por- 
tions of  the  mandible  in  their  proper  position  until  a  bone-graft  could 
later  be  placed  between  them.  Very  few  of  the  cases  coming  to  us  had 
sufficient  teeth  properly  to  place  such  a  splint. 


GUNSHOT  WOUNDS  AND  FRACTURES  OF  FACE  AND  J  A  WS    695 

This  same  patient  developed  septic  pneumonia.     He   entered  the 
hospital  with  a  temperature  of  103.5°  F.     Generally  such  cases  die 


Fig.  552. — Badiographs  of  case  shown  in  Figs.  550  and  551.  A  shows  the  fractured 
jaw;  B,  a  Sherman  four-hole  metal  plate  fastened  by  two  screws  in  the  posterior  frag- 
ment, to  bridge  the  defect  in  the  jaw-bone.     (Dental  Cosmos.) 


696       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

before  they  can  l)e  brought  to  the  base  hospital.     The    condition  of 
the  wounded  during  a  big  offensive  is  terrible.    At  the  battle  of  Loos 


Fig  553  —Radiographs  of  the  same  case  iUustrated  in  Figs.  550,  551  and  552  B 
shows  the  jaw  after  the  removal  of  the  metal  plate  and  the  successful  umon  of  a  bone 
graft  taken  by  Dr.  Greenough  from  the  fifth  rib  sUghtly  anterior  to  the  sternal  cartilage. 


GUNSHOT  ]rOUNDS  AND  FRACTURES  OF  FACE  AND  JAWS     697 

the  dead  could  not  })e  quickly  removed  from  between  the  firing  lines. 
At  night  the  soldiers  would  crawl  out,  drag  the  bodies  back  to  the 
trenches,  and  then  throw  dirt  over  them.  Thus  many  dead  were  buried 
right  in  front  of  the  trenches.  When  a  shrapnel  hit  such  a  spot  the 
horrible  mess  was  spread  in  all  directions.  Can  you  wonder  that 
shrapnel  wounds  are  so  septic? 


Fig.  554. — Shows  a  denture  used  in  a 
case  in  which  there  was  a  total  destruc- 
tion of  chin,  lower  lip  and  forepart  of  the 
floor  of  the  mouth  and  also  of  the  hori- 
zontal portion  of  the  mandible  from  the  left 
second  molar  to  the  right  third  molar.  The 
dentxire  was  made  and  hinged  by  wires 
passing  into  the  tubes  and  held  by  means 
of  elastic  bands  passing  from  this  to  a 
wire  splint  fastened  to  the  upper  teeth. 
This  served  to  restore  the  mandible  so  far 
as  possible  and  acted  also  as  a  shield  over 
which  to  mold  the  skin  flap  from  the  fore- 
arm. This  flap  was  sewn  to  the  left  side 
of  the  wound  on  the  face  after  its  margin 
had  been  freshened.  Fifteen  days  later 
the  flap  was  separated  from  the  arm  and 
sutured  into  the  wound.  The  red  margin 
of  the  Hps  was  reproduced  by  three  flaps 
of  the  mucous  membrane  taken  from  the 
lining  of  the  mouth.  (After  the  War  Sup- 
plement of  the  British  Dental  Journal.) 


Fig.  555. — Shows  in  dotted  outline, 
a  b  c  d,  double  epithelized  flap  from  right 
forearm;  d  f  g  and  g  f  c  e,  flap  taken  from 
neck.  The  red  margin  of  the  lip  taken 
from  the  mucous  membrane  of  the 
mouth.  (After  War  Supplement,  British 
Dental  Journal.) 


The  treatment  in  this  case  was  that  used  successfully  in  many 
others,  and  was  as  follows:  German  silver  pinch  bands  were  placed 
on  a  nimiber  of  the  lower  teeth  on  either  side  of  the  fracture.  The 
ends  of  these  pinch  bands  were  allowed  to  project  outward.  Then  the 
upper  and  lower  teeth  were  wired  together,  thus  bringing  them  to 
normal  occlusion  and  reducing  the  fracture.  Next  an  impression  was 
taken  of  the  buccal  and  labial  surfaces  of  the  teeth,  together  with  the 
ends  of  the  pinch  bands.     This  impression  was  removed,  the  pinch 


698       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 


Fig.  556. — Illustrates  pure  tin  shields  in  place  over  which  plastic  operations  are  per- 
formed as  in  the  Diisseldorf  Hospital.  These  shields  are  attached  to  splints  and  occa- 
sionally to  the  teeth.  They  support  the  flaps  and  are  a  guide  to  the  depth  and  fulness 
of  the  lips  in  plastic  restorations  thereof.  (After  the  War  Supplement  of  the  British 
Dental  Journal.  Cases  from  the  hospital  at  Diisseldorf,  by  W.  H.  Dolamore,  L.R.C.P., 
M.R.C.S.,  L.D.S.) 


Fig.  557. — Shows  injury  caused  by  a 
bullet.  The  nasal  septum,  the  tip  of  the 
nose,  the  hard  palate  and  a  considerable 
portion  of  the  alveolar  border  was  de- 
stroyed. The  fractured  mandible  was 
treated  with  a  tinned  wire  sphnt.  The 
lip  was  replaced  and  kept  in  position  by 
means  of  two  wire  hooks  strapped  to  the 
forehead  and  supplemented  with  gauze. 


Fig.  558. — Shows  the  same  case  after 
wound  had  been  surgically  closed  and  the 
nasal  injury  corrected  and  illustrates  the 
benefit  of  supporting  portions  of  the  lip 
and  jaw  that  otherwise  would  hang  down. 
(After  the  War  Supplement  of  the  British 
Dental  Journal.  Cases  from  the  hospital 
at  Diisseldorf,  by  W.  H.  Dolamore, 
L.R.C.P..  M.R.C.S..  L.D.S.) 


GUNSHOT  WOUNDS  AND  FRACTURES  OF  FACE  AND  JAWS    699 

bands  were  taken  from  the  teeth  and  properly  placed  in  the  impression, 
and  an  investment  was  made  with  the  bands  in  position.  After  cutting 
off  the  projections  of  the  pinch  bands  a  heavy  German  silver  wire  was 


Fig.  560 
Figs.  559  and  560. — Show  tin  splint  made  in  three  pieces  hinged  posteriorly  and 
placed  in  position  vrired  to  the  teeth.  Modelled  by  Hauptmeyer  on  a  \'ulcanized  splint 
designed  by  Kersting  and  described  in  the  Deutsche  med.  Wochenschrift,  1904.  (After 
the  War  Supplement  of  the  British  Dental  Journal.  Cases  from  the  Hospital  at  Diissel- 
dorf,  by  W.  H.  Dolamore,  L.R.C.P.,  M.R.C.S.,  L.D.S.) 

soldered  to  the  bands  on  both  the  buccal  and  lingual  surfaces.    The 
wiring  was  then  removed  from  the  teeth,  and  this  splint  was  cemented 
in  place. 
In  the  War  Supplement  of  the  British  Dental  Journal,  Dr.  A.  Pont, 


700       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

of  Lyons,  reports  among  the  cases  treated  at  the  Lyons  Stomatological 
center  the  case  of  oculofacial  prosthesis  shown  in  Figs.  554  and  570. 


Fig.  561  Fig.  562 

Figs.  561  and  562. — Show  splint  made  of  wire  attached  to  military  cap  to  hold  the 
anterior  portion  of  the  mandible  where  it  is  torn  away  from  the  posterior  portions  to 
prevent  the  front  fragment  from  dropping  downward  with  the  attached  muscle  of  the 
tongue  and  thus  impeding  breathing  and  swallowing.  This  splint  was  designed  by 
Hauptmeyer  who  used  it  repeatedly  in  the  field.  (After  War  Supplement,  British  Dental 
Journal,  1916.) 


Fig.  563. — Shows  nasal  splint  designed  by  Ernst  and  sold  in  Germany  ready  made. 
The  vertical  bars  end  in  two  iron  plates ;  these  are  embedded  in  a  plaster  bandage  and  fixed 
to  the  head.  Additional  support  is  given  by  two  lead  plates  on  each  side  at  the  malar 
bones.  This  apparatus  is  adjustable  and  used  to  support  the  nose  and  preserve  the  form 
of  the  nares  during  the  healing  process  after  injury.  It  consists  of  a  double  lever  with  a 
plug  inserted  into  the  nares,  force  exerted  by  elastic  bands  and  obtained  by  a  wire  soldered 
to  a  metal  cap,  cemented  to  the  upper  front  teeth,  or  if  necessary,  fixed  to  a  head  bandage. 
Various  forms  of  this  appliance  have  been  used  at  the  Diisseldorf  Hospital.  (After  the 
War  Supplement  of  the  British  Dental  Journal.) 


GUNSHOT  WOUNDS  AND  FRACTURES  OF  FACE  AND  JAWS     701 

Fig.  570  may  be  taken  as  a  good  example  of  the  wonderful  work  of 
this  character  that  is  now  being  done  in  the  reconstruction  of  faces 
disfigured  by  war  wounds.    In  the  case  of  simple  loss  of  the  substance 


Fio.  564. — Shows  the  character  of  a  wound  treated  according  to  the  methods  of 
Lindemann  by  plastic  operations,  as  illustrated  in  Figs.  565  and  566,  and  treatment  by 
exposure  to  the  air  and  the  sun's  rays,  alternately,  suction  glasses  and  washing. 

of  the  eyeball,  with  preservation  or  efficient  reconstruction  of  the  eyelid, 
the  prosthesis  is  the  work  of  the  oculist.  In  cases  where  an  artificial 
eye  cannot  be  placed,  in  consequence  of  the  disappearance  of  an  eyelid 


Fig.  565.  —  abed,  efghi,klmn,  newly 
formed  flaps  with  bases  at  a  d,  a  i,  kn;  dopn, 
extent  of  pared  edges  of  wound. 


Fig.  566. — After  suturing  the  flaps  in 
position. 


or  any  other  cause,  but  when,  however,  there  is  not  very  much  loss 
of  peri-orbital  tissue,  the  insertion  of  a  replacing  prosthesis  such  as  we 
describe  can  be  effected  by  an  instrument  in  vulcanite  or  painted  metal 


702       TREATMENT  OF  WOUNDS  UNDER  WAR  CONDITIONS 

held  in  place  by  spectacles.  This  is  the  way  to  proceed:  One  simply 
makes  a  mask  of  the  upper  part  of  the  face;  this  serves  as  a  model 
round  which  to  make  the  artificial  eye  and  to  model  the  eyelid  in  wax; 


Fig.  567  Fi.i   :Ais 

Fig.  567  and  568. — Show  wound   closed   with  sutures  in  place.     Same  case  illustrated 

in  Fig.  564.     (After  War  Supplement  of  the  British  Dental  Journal.) 

now  one  puts  into  the  wax  a  piece  of  metal  which  will  serve  as  support 
to  the  instrument  and  will  be  placed  on  the  upper  part  of  the  rim  of  the 
spectacles. 


(^ 

'i 

J 

j^^^       ■-•■  ' 

im 

■■■••-^-^r- 

''^Jm 

RblMa^ 

mM 

Fig.  569. — Shows  loss  of  eye  and  sur- 
rounding tissue. 


Fig.  570. — Shows  the  restoration  of  an 
eye  attached  to  spectacles.  (After  War 
Supplement  of  theBritishDentalJournal.) 


As  soon  as  the  wax  molding  is  finished,  one  substitutes  vulcanite 
for  this  wax  as  is  done  in  dental  prosthesis;  the  appliance  is  cast  in  two 


MASKS  OF  COPPER  SILVER  PLATED  703 

parts  in  a  bronze  flask,  the  wax  is  removed  from  the  flask  by  boihng  in 
water  and  replacino;  it  by  rubber  which  is  hardened  by  vulcanizing  in 
a  M^dcanizer  at  the  temperature  of  165°  for  one  hour. 

After  poUshing  it,  the  apphance  can  be  painted,  or  better  still, 
coated  with  hard  paraffin,  tinted;  one  thus  makes  over  the  \ailcanite 
a  true  picture  in  wax,  the  surface  of  which  represents,  well  enough,  the 
dull  aspect  of  the  skin.  The  color  being  obtained,  one  traces  on  the  two 
palpebral  margins  a  little  groove  in  which  to  place  the  threads,  securing 
the  artificial  eyelashes,  and  the  appliance  is  held  in  place  by  appropriate 
spectacles  (Fig.  570). 

MASKS  OF  COPPER  SILVER  PLATED. 

The  method  of  the  English  sculptor.  Captain  Derwent  Wood,  of 
Hospital  No.  2,  London,  which  has  been  used  with  such  wonderful 
success  by  Madam  INIaynard  Ladd,  of  Paris,  is  as  follows:  (1)  the  taking 
of  a  plaster  cast  of  the  face ;  (2)  the  making  of  a  mask  in  the  image  of 
a  photograph  taken  prior  to  the  wounds;  (3)  the  making  of  the  silver- 
plated  copper  mask;  (4)  coloring  these  masks  to  give  perfect  resem- 
blance. The  result  of  the  efforts  of  these  great  artists  is  said  to  be 
wonderful  beyond  conception  in  effecting  the  transfiguration  of  war- 
scarred  and  deformed  faces. 


SELECTED  LIST  OF  EXAMINATION  QUESTIONS. 

(Be  particular  to  know  the  answers  to  the  questions  indicated  in  italics.) 

ANESTHESIA. 

1.  Define  anesthesia,  page  17 

2.  Define  analgesia,  page  17 

3.  Define  hyperesthesia,  page  236 

4.  Define  paresthesia,  page  236 

5.  Give  tu-o  principal  for7ns  of  anesthesia,  page  17 

6.  Name  the  agents  most  commonly  used  for  inducing  general  anesthesia, 
page  17 

7.  WTiat  local  anesthetic  agents  are  most  frequently  employed?  pages  18,  19,  20 

8.  How  may  careless  use  of  local  anesthetics  in  the  mouth  lead  to  serious  results? 
page  18 

9.  Describe  the  technic  of  infiltration  anesthesia  for  the  roots  of  the  anterior 
teeth,  pages  20-22 

10.  Describe  the  injection  to  block  the  inferior  dental  nerve  at  the  Ungula 
according  to  the  modified  Braun  method,  pages  23,  24 

11.  Give  the  method  of  conduction  anesthesia  for  the  upper  jaw,  page  25 

12.  How  may  the  sphenopalatine  injection  be  accomphshed?  pages  26-28 

13.  For  what  purpose  are  local  anesthetic  agents  sometimes  used  in  combination 
with  other  anesthetics  for  surgical  operation/  page  18 

14.  Is  it  adAdsable  to  give  an  injection  of  morphin  and  atropin  before  surgical 
operation,  and  why?  page  34 

15.  Describe  infiltration  anesthesia,  page  20 

16.  What  conditions  shordd  govern  the  choice  of  a  general  anesthetic?  pages  20,  28-32 

17.  What  is  the  relative  safety  in  administration  of  chloroform,  ether,  nitrous 
oxide  gas  and  somnoform?  pages  28-32,  35 

18.  Describe  the  desirable  conditions  for  anesthesia  for  mouth  operations,  pages 
32-35 

19.  Describe  the  preparation  of  a  patient  for  general  anesthesia,  pages  35-38 

20.  In  a  general  way  give  the  relative  values  of  the  preparations  most  used  for 
infiltration  and  conduction  anesthesia,  pages  20-28 

HEMORRHAGE. 

1.  Define  hemorrhage,  page  38 

2.  Name  the  recognized  forms  of  hemorrhage,  pages  38,  39 

3.  What  are  the  causes  of  hemorrhage?  page  38 

4.  Give  classification  of  the  principal  forms  of  hemorrhage,  page  39 

5.  Define  epistaxis,  hemoptysis,  gastrorrhagia,  hemorrhagic  infarcts,  hematoma, 
enter orrhagia,  metrorrhagia,  menorrhagia,  ecchymosis,  pages  38,  39 

6.  What  is  meant   by   primary  hemorrhage,  reactionary  hemorrhage,  and  sec- 
ondary hemorrhage?  page  39 

7.  What  are  the  local  symptoms  of  hemorrhage?  page  39 

8.  What  are  the  general  symptoms  of  severe  hemorrhage?  page  39 

9.  Describe  fifteen  methods  of  arresting  hemorrhage,  page  39 

10.  Describe  the  following  terms  as  applied  to  the  arrest  of  hemorrhage:  ligation, 
forcipressure,  tourniquet,  Esmarch's  bandage,  styptics,  constitutional  treatment,  direct 
transfusion  of  blood,  intravenous  infusion,  proctoclysis,  hypodermoclysis,  heat 
cold,  position,  pressure,  page  39 

11.  What  preparatory  treatment  may  be  employed  in  preparation  to  avoid  grave 
results  from  hemorrhage  during  surgical  operation?  page  40 

12.  Describe  the  treatment  of  grave  hemorrhage  and  give  the  remedial  yneasures  in 
accordance  with  the  indications  of  the  symptoms,  pages  40,  41,  52 

13.  Is  human  blood  transfusion  beneficial  in  cases  of  hemophiha?  pages  49-51 

14.  Describe  a  method  of  indirect  transfusion  and  give  the  dangers  to  be  avoided 
in  the  procedure,  pages  43-47 

(704) 


SELECTED  LIST  OF  EXAMINATION  QUESTIONS  705 

SHOCK. 

1.  Define  shock,  page  52 

2.  Enumerate  some  of  the  psychic  and  operative  causes  of  shock  in  surgical 
conditions,  pages  52,  53 

3.  Name  some  of  the  predisposing  and  also  important  direct  factors  in  shock, 
page  53 

4.  Describe  the  symptoms  of  shock  in  a  graduated  way  from  simple  to  grave  condi- 
tions, page  55 

5.  Describe  coma,  page  55 

6.  What  prophylactic  treatment  may  be  given  in  anticipation  of  shock  to  reduce 
its  severity?  pages  55,  56 

7.  Give  postoperative  treatment  of  surgical  cases  with  reference  to  shock,  pages 
56-58 

PATHOLOGICAL   DENTITION. 

1.  Name  and  classify  the  principal  causes  of  pathological  dentition,  page  59 

2.  Give  the  local  and  general  symptoms  of  difficult  dentition  in  infants  and  adults, 
pages  60,  61  • 

3.  How  may  serious  general  symptoms  occur  in  infant  cases  during  tooth  erup- 
tions? page  59 

4.  Haw  may  malposed  or  unerupted  teeth  be  diagnosticated?  page  62 

5.  Desa-ibe  the  principles  governing  treatment  of  delayed  or  difficidt  eruption  of 
teeth  in  infants  and  adults,  pages  62-70 

6.  Describe  the  steps  in  operation  for  the  removal  of  malposed  third  molars 
with  reference  to  anesthesia,  asepsis,  position  of  patient,  control  of  field  of  opera- 
tion, and  exposure  of  the  embedded  tooth  crown,  pages  70,  72-76 

7.  Describe  the  symptoms  and  preliminary  treatment  of  a  case  of  impacted  third 
molar  tooth  and  tell  what  other  affections  the  symptoms  may  simulate  and  how  they 
may  be  differentiated  in  diagnosis,  pages  67,  69 

8.  What  are  the  chief  dangers  to  be  avoMed  in  the  surgical  removal  of  impacted 
teeth?  pages  71,  72 

WOUNDS. 

1.  Define  a  wound,  page  76 

2.  Give  classification  of  the  different  varieties  of  wounds,  page  76 

3.  Describe  the  repair  of  wounds,  page  76 

4.  What  is  meant  by  the  terms  immediate  union,  healing  by  first  intention,  by 
second  intention,  and  by  granulation  surface?  pages  76,  77 

5.  Describe  six  steps  in  the  treatment  of  wounds  in  the  order  of  their  importance, 
pages  77,  78 

6.  Describe  the  treatment  of  wounds  of  the  mauth,  with  special  reference  to  local 
conditions,  pages  79-81 

7.  What  essential  properties  muM  dressings  for  wounds  of  the  mouth  possess? 
page  78 

8.  WTiat  has  been  the  influence  of  the  use  of  antitoxin  in  preventing  tetanus 
in  the  present  war?  page  668 

9.  What  is  Dakin's  solution?  page  6G8 

10.  Give  the  Carrel  method  of  using  Dakin's  solution,  page  669 

INFECTIOUS   DISEASES. 

1.  Define  septic  intoxication,  infection,  poisons,  toxemia,  sapremia,  septicemia, 
mycosis,  pyemia,  bacteriemia,  auto-intoxication,  pyrexia,  pages  82,  83 

2.  Describe  aseptic  fever  and  septic  fever,  pages  84,  85 

3.  What  are  the  causes  of  aseptic  ivound  fever?  page  84 

4.  Describe  the  symptoms  of  aseptic  wound  fever,  page  84 

5.  Give  the  causes,  symptoms,  and  treatment  of  septic  fever,  pages  85-90 

6.  Differentiate  by  their  symptomatic  indications  toxemia,  true  septicemia,  and 
pyemia,  pages  85,  86 

7.  What  is  the  purpose  of  vaccine  therapy?  pages  89,  90 

8.  What  is  meant  by  autogenous  vaccine?  page  90 

9.  Define  anaphylaxis,  page  90 

10.  What  foundation  is  there  for  the  theory  of  the  transmutation  of  micro- 
organisms? pages  142,  143 
45 


706  SELECTED  LIST  OF  EXAMINATION  QUESTIONS 

11.  How  may  focal  infection  of  oral  origin  be  a  factor  in  the  causation  of  remote 
diseases?  page  143 

12.  Describe  the  diagnostication  of  bh'nd  abscesses,  and  their  importance,  page 
146 

TETANUS. 

1.  Define  tetanus,  page  90 

2.  Give  the  etiology  of  tetanus,  page  90 

3.  What  is  the  approximate  period  of  incubation  in  tetanus?  page  91 

4.  What  are  the  symptoms  of  tetanus?  page  91 

5.  What  are  the  recognized  forms  of  this  affection?  pages  91,  92 

6.  Describe  the  symptoms  of  acute,  chronic,  and  cephalic  tetanus,  pages  91,  92 

7.  What  diagnostic  indications  differentiate  tetanus  from  other  spasmodic  affec- 
tions, page  92 

8.  Describe  the  prophylactic  treatment  that  shoidd   be  given  in  grave  accidental 
injuries  if  tetanus  is  apprehended,  page  34 

9.  What  kind  of  injuries  most  frequently  result  in  tetanus?  pages  90,  91 

10.  Describe  the  treatment  of  tetanus,  pages  92-94 

11.  What  is  the  primary  cau.se  of  death  in  tetanus?  page  92 

TUBERCULOSIS. 

1.  Define  tuberculosis,  page  94 

2.  What  are  the  portals  of  entrance  of  tubercle  bacilli  into  the  human  body?  page  95 

3.  What  are  the  principal  forms  of  tuberculosis?  pages  96,  97 

4.  Describe  the  treatment  of  tubercular  necrosis,  page  103 

5.  Give  the  symptoms  of  tuberculosis,  pages  99,  100 

6.  Describe  the  methods  of  diagnosis  in  tubercular  cases,  pages  99-101 

7.  Describe  Koch's  tuberculin  test,  the  cutaneous  reaction,  ophthalmic  reac- 
tion, pages  100,  101 

8.  Describe  the  basal  principles  of  some  of  the  most  important  measures  for  the 
prevention  of  tuberculosis,  pages  101,  107 

SYPHILIS. 

1.  Define  syphilis,  page  107 

2.  What  is  meant  by  the  hereditary  and  acquired  forms  of  this  disease?  pages 
107,  110 

3.  How  may  syphilis  be  transmitted  by  heredity?  page  107 

4.  Describe  Hutchinson's  teeth,  pages  108,  109 

5.  7.S  extragenital  inoculation  a  frequent  cause  of  syphilis?  page  110 

6.  What  are  the  dangers  to  be  apprehended  from  this  cause  in  dental  practice  and 
how  may  they  be  avoided?  page  111 

7.  Describe  the  symptoms  of  acquired  syphilis  according  to  stages,  pages  112-114 

8.  What  is  the  period  of  primary  incubation  and  how  long  does  it  last?  page  112 

9.  Describe  the  secorulary  incubation  period  and  give  the  approximate  time  of  its 
duration,  pages  112,  113 

10.  Describe  the  tertiary  symptoms  and  tell  how  early  they  might  be  expected  to 
appear,  and  how  long  after  infection  they  may  be  manifested,  page  114 

11.  Describe  chancre,  chancroid,  mucous  patches,  gumma,  pages  116-119 

12.  Give  the  cardinal  symptoms  of  the  three  stages  of  syphilis,  pages  112-114,  118, 
119 

13.  Describe  the  W"a.ssermann  test,  page  121 

14.  Differentiate  diagnostically  between  chancre  and  chancroid,  page  117 

15.  Describe  the  prophylactic  treatment  of  syphilis  and  tell  when  it  must  be  instituted 
in  order  to  be  effective,  page  123 

16.  Describe  the  treatment  of  chancre  and  tell  why  it  differs  from  the  treatment  of 
chancroid,  pages  124,  128 

17.  Give  in  a  general  way  the  treatment  of  secondary  and  tertiary  syphilis,  pages 
125-127 

18.  Give  the  prognosis  of  syphilis,  pages  107,  111,  114,  124 

19.  What  is  salvarsan  and  how  is  it  administered  in  syphilitic  treatment?  page  127 

20.  May  destruction  of  the  maxillary  bones  occur  as  with  other  structures  through 
the  extension  of  lesions  affecting  the  soft  tissues  in  the  early  stages  of  tertiary  syphilis? 
page  121 


SELECTED  LIST  OF  EXAMINATION  QUESTIONS  707 

21.  What  general  instructions  should  be  given  syphilitic  patients,  especially 
when  the  disease  is  first  recognized?  page  123 

22.  How  may  mercury  be  administered  in  the  treatment  of  syphilis?  pages 
124-126 

23.  What  mouth  indications  ivonld  be  important  in  detecting  mercurialism?  pages 
118,  126 

ACTINOMYCOSIS. 

1.  Define  actinomycosis,  page  129 

2.  Give  the  etiology  of  actinomycosis,  page  129 

?.  Describe  the  symptoms  of  actinomycosis  of  the  cervical  facial  regions,  page  130 
4.^  What  are  the  diagnostic  indications  of  actinomycosis?  pages  132,  134 
5.  Describe  the  treatment  of  actinomycosis,  pages  133-134 

GLANDERS. 

1.  Define  glanders,  page  134 

2.  Define  farcy,  page  134 

3.  Give  the  etiology  of  glanders,  page  134 

4.  Describe  the  diagnosis  of  glanders,  pages  135,  136 

5.  What  treatment  may  be  employed  in  these  cases?  page  136 

ANTHRAX. 

1.  Define  anthrax,  page  136 

2.  Give  etiology  of  anthrax,  page  137 

3.  Describe  the  symptoms  and  treatment  of  this  infection,  pages  137-139 

LEPROSY. 

1.  Define  leprosy,  page  139 

2.  Describe  the  tubercular  and  anesthetic  forms  of  this  disease,  pages  139,  140 

DISEASES  OF  THE   MUCOUS   MEMBRANE   OF  THE   MOUTH. 

1.  Define  stomatitis,  page  151 

2.  Describe  the  etiology,  symptoms,  and  treatment  of  gingivitis,  pages  151-154 
Describe  interstitial  gingivitis  (pyorrhea  alveolaris),  page  151 

Describe  stomatitis  simplex,  page  154 

Describe  aphthous  stomatitis  (stomatitis  aphthosa),  page  155 

Describe  Bednar's  aphthse,  page  156 

Describe  ulcerative  stomatitis,  page  156 

Describe  gangrenous  stomatitis,  pages  157-160 

Describe  parasitic  or  mycotic  stomatitis  (thrush),  page  160 

Describe  foot-and-mouth  disease,  page  160 

Describe  pseudomembranous  stomatitis,  page  161 

Describe  phlegmonous  stomatitis,  page  162 

Describe  tubercular  stomatitis,  pages  99,  102,  162 

Describe  actinomycotic  stomatitis,  pages  130,  131,  133 

Describe  leukemic  stomatitis,  pages  162-167 

3.  May  stomatitis  be  a  symptom  of  glanders  and  leprosy?  pages  167,  168 

4.  Describe  the  etiology,  symptoms,  and  treatment  of  Ludwig's  angina,  pages 
168,  169 

5.  Give  the  etiology,  symptoms  and  treatment  of  Vincent's  angina,  pages  169, 
170 

6.  Have  the  diphtheroid  bacillus  and  spirillum  of  Vincent's  angina  been  found 
in  gangrenous  stomatitis  (noma)?  pages  169,  170 

7.  Describe  gonorrheal  ulcerative  stomatitis,  page  171 

8.  Define  pemphigus,  page  171 

9.  What  forms  of  pigmentation  may  affect  the  mucous  membrane  of  the  mouth? 
pages  171,  172 

10.  Tell  some  of  the  reasons  why  traumatic  injuries  of  the  mucous  membrane  of  the 
mouth  due  to  nervous  habits  may  bear  an  important  relation  to  serious  pathological 
conditions,  page  173 

11.  Describe  the  terms,  first,  second,  and  third  degree  as  applied  to  burns  and  scalds 
of  the  mucous  membrane  of  the  mouth,  page  174 


708  SELECTED  LIST  OF  EXAMIXATIOX  QUESTIONS 

12.  Describe  erythema  endemicum  (pellagra),  page  178 

13.  Define  urticaria,  page  178 

14.  Deiine  herpes  simplex,  page  179 

15.  Define  lichen  planus,  page  179 

16.  Define  purpura,  page  183 

17.  Describe  eczema  labialis,  page  183 

18.  Give  etiology,  symptoms,  and  treatment  of  scorbutic  stomatitis,  page  184 

19.  Give  etiology,  symptoms,  and  treatment  of  infantile  scorbutus,  pages  185-189 

20.  Give  etiology,  symptoms,  and  treatment  of  blastomycosis,  page  190 

21.  Give  etiology,  symptoms,  and  treatment  of  erysipelas,  pages  190,  191 

22.  Give  etiology,  symptoms,  and  treatment  of  leukoplakia,  pages  181,  182 

X.  B.— (Be  particular  to  know  thoroughly  the  affections  indicated  in  italics.) 


DISEASES  OF   THE   NERVOUS  SYSTEM. 

1.  Define  neuritis,  page  192 

2.  Give  the  principal  causes  of  neuritis,  page  193 

3.  Describe  the  sjTnptoms  of  neuritis,  pages  193,  194 

4.  In  the  treatment  of  cases  of  neuritis  without  direct  injury-  to  the  affected 
ner\-es,  what  measures  may  be  employed  to  give  relief?  page  194 

5.  Define  neuroma,  page  195 

6.  Name  five  reasons  why  diseases  of  the  spinal  cord  may  bear  an  important 
relation  to  buccal  affections,  page  197 

7.  Define  sjTingomyeUa,  page  197 

8.  What  are  the  most  notable  symptoms  of  s\TingomyeUa?  pages  197,  198 

9.  Define  acute  anterior  or  infantile  paralysis  or  pohomj-eUtis,  page  198 

10.  Should  mouth  disinfection  he  rigidly  maintained  during  treatment  in  cases  of 
infantile  paralysis,  and  why?  page  201 

11.  Describe  chronic  anterior  poUomyehtis,  page  201 

12.  Define  amyotrophic  lateral  sclerosis,  page  201 
Define  muscular  dystrophy,  page  203 

Define  acute  progressive  paralysis,  page  211 
Define  locomotor  ataxia,  page  211 
Define  Friedreich's  ataxia,  page  212_J 
Define  spinal  meningitis,  page  214 

13.  Describe  bulbar  paralysis,  page  224 


DISEASES  OF  THE  BRAIN. 

1.  What  are  the  chief  reasons  why  cerebral  diseases,  particularly  cerebral  hemor- 
rhage, cerebral  embolism,  and  cerebral  thrombosis,  are  sometimes  of  diagnostic  impor- 
tance to  the  oral  surgeon?  page  215 

2.  Describe  the  sjTnptoms  of  intracranial  pressure,  page  215 

3.  Define  encephalitis  and  tell  why  its  symptoms  sometimes  affect  the  buccal  region, 
page  217 

4.  Why  may  oral  hygiene  be  an  influential  factor  in  the  prevention  of  meningitis? 
page  218 

5.  Give  the  cardinal  symptoms  of  meningitis,  page  218 

6.  In  what  way  may  brain  abscess  have  an  important  diagnostic  as  well  as  etio- 
logical relation  to  diseases  of  the  mouth  and  jaws?  page  221 

7.  Explain  why  it  is  necessary  to  distinguish  symptoms  appearing  iii  the  head 
and  face  in  brain  tumor  from  those  which  may  be  indications  of  less  serious  affec- 
tions in  order  that  early  diagnosis  may  be  facilitated,  page  222 

8.  Give  the  general  sjinptoms  of  brain  tumor,  page  222 

9.  What  are  the  symptoms  of  bulbar  palsy?  page  225 

10.  May  oral  diseases  be  a  factor  in  causing  anosmia  or  loss  of  smell,  and  how? 
page  227 

11.  Why  should  examination  of  the  eye  for  choked  disk  be  considered  in  diagnosis 
of  nerve  disturbances  in  the  regions  of  the  face  and  jaws?  page  227 

12.  Paralysis  of  what  nerve  causes  patheticus  paralysis?  page  229 

13.  Through  the  affection  of  what  nerve  is  abducens  paralysis  caused?  page  229 


SELECTED  LIST  OF  EXAMINATION  QUESTIONS  709 

AFFECTIONS   OF   THE   FIFTH   NERVE. 

1.  Describe  the  effect  of  paralysis  of  the  motor  division  of  the  fifth  nerve,  page  232 
''      2.  How  may  tinnitus  aurium  result  from  this  cause?  pages  233,  300 
S[  3.  Describe  hemiatrophy  of  the  face,  page  233 

4.  Name  some  of  the  dental  and  oral  causes  of  spasmodic  conditions  of  the 
muscles  of  mastication,  page  235 

.5.  Is  herpes  zoster  sometimes  associated  with  affections  of  the  fifth  nerve, 
and  how  is  this  evidenced?  page  235 

G.  How  may  anesthesia,  hyperesthesia,  and  paresthesia  be  cause!   by  aifections 
of  the  trigeminal  nerve?  pages  236,  237 

7.  Define  pain,  headache,  migraine,  neuralgia,  and  tic  douloureux,  pages  238-247 

8.  Give  classification  of  the  clinical  types  of  neuralgia,  page  240 

'    9.  Give  four  general  divisions  of  the  causes  of  neuralgia,  pages  241,  242 

10.  Enumerate  some  of  the  importaiil  considerations  in  the  diagnosis  of  trigeminal 
neuralgia,  page  244 

11.  What  are  the  distinguishing  symptoms  of  tic  douloureux?  pages  244,  245 

12.  Describe  the  non-surgicil  treitmenl  of  trigeminal  neuralgia,  pages  248-258 

13.  Describe  the  method  of  deep  alcoholic  injection  of  the  superior  maxilliary 
division  of  the  fifth  nerve  at  the  foramen  rotundum,  pages  251-254 

14.  Describe  the  method  of  deep  alcoholic  injection  of  the  inferior  maxillary 
division  of  the  fifth  nerve  at  the  foramen  ovale,  pages  251-254 

15.  Describe  the  method  of  the  alcoholic  injection  of  the  Gasserian  gangUon, 
pages  254-257 

16.  What  dangers  are  to  be  avoided  in  deep  alcohohc  injection  of  the  fifth 
nerve?  pages  251-254 

17.  What  is  the  danger,  and  what  compUcations  may  follow  the  alcoholic  injec- 
tion of  the  Gasserian  ganghon?  page  257 

18.  What  benefit  may  be  expected  from  alcoholic  injections  in  tic  douloureux? 
page  258 

19.  Describe  neurotomv,  neurectomy,  nerve  extraction,  and  nerve  stretching  in 
relation  to  neuralgia  of  the  fifth  nerve,  page  258 

20.  Under  ivhat  conditions  should  the  removal  of  the  Gasserian  ganglion  be  advised? 
page  269 

21.  Describe  the  most  important  forms  of  dental  irritation  that  may  cause  neuralgia, 
pages  281-286 

AFFECTIONS  OF  THE  SEVENTH  OR  FACIAL   NERVE. 

1.  What  are  the  symptoms  of  facial  paralysis?  page  294 

2.  Name  some  of  the  causes  of  facial  paralysis,  pages  293,  294 

3.  Give  the  diagnostic  indications  of  central  or  peripheral  nerve  disturbances  in 
facial  paralysis,  page  295 

AFFECTIONS  OF  THE  EIGHTH  NERVE. 

1.  Describe  tinnitus  aurium,  page  300 

2.  Can  tinnitus  aurium  be  caused  by  mouth  affections?  page  300 

AFFECTIONS   OF   THE   NINTH  AND   TENTH   NER\^S. 

1.  What  relation  have  affections  of  these  nerves  to  palate  and  mouth  conditions? 
page  301 

AFFECTIONS  OF  THE  ELEVENTH  NERVE. 

1.  Describe  the  symptoms  of  paralysis  of  the  spinal  accessory  nerve,  page  302 

2.  How  may  mouth  infection  be  a  causal  factor  in  these  cases?  page  302 

LESIONS  OF  THE  HYPOGLOSSAL  NERVE. 

1.  Name  the  prominent  symptoms  of  paralysis  of  the  hypoglossal  nerve,  page  302 

SPASMODIC   NEUROSES. 

1.  What  relation  may  irritation  of  the  fifth  nerve  from  dental  and  oral  disorders 
bear  to  facial  spasm,  chorea  and  epilepsy?  pages  303,  304,  309,  310 

2.  Define  tonic  and  clonic  spasms,  page  303 


710  SELECTED  LIST  OF  EXAMINATION  QUESTIONS 


NERVOUS   DISEASES. 

1.  Define  hysteria,  neurasthenia,  angioneurotic  edema,  and  trophic  changes,  and 
tell  how  these  conditions  may  be  subject  to  oral  influences,  pages  313-317 

DISEASES  OF  BONE. 

1.  Define  osteogenesis,  and  describe  its  relation  to  osteoclasts,  osteoblasts,  and 
osseous  apposition,  page  318 

2.  Defiine  bone  atrophy  in  relation  to  lacunar  absorption,  perforating  canal  absorp- 
tion, osleop  irosis,  and  halisteresis,  page  318 

3.  Describe  local  and  constitutional  forms  of  halisteresis,  page  318 

4.  Describe  osteomalacia,  page  318 

5.  How  may  bone  regeneration  occur?  page  319 

6.  Describe  pressure  atrophy  of  bone,  page  319 

7.  Name  the  general  causes  of  malformation  of  bone,  pages  319,  320 

8.  Defirie  agenesis  and  osteogenesis  imperfecta,  page  320 

9.  Describe  rickets,  acromegaly,  facial  hemihypertrophy,  leontiasis  ossea,  osteitis 
deformans,  pages  320,  321,  322,  323,  324 

DISEASES  OF  THE   PERIOSTEUM. 

1.  Give  the  principal  causes  of  hemorrhage  under  the  periosteum,  page  324 

2.  Describe  simple,  purulent,  and  osteoperiostitis,  pages  324,  325 

3.  Describe  the  symptoms  of  circumscribed  and  diffuse  purulent  periostitis,  page 
325 

4.  Give  the  treatment  of  periostitis  in  its  various  forms,  page  325 

INFLAMMATION  OF  BONE. 

1.  Name  two  recognized  forms  of  inflammation  of  bone,  page  326 

2.  Define  and  give  etiology,  pathology,  symptoms,  and  treatment  of  necrosis  and 
caries,  pages  326-331,  333-338 

3.  Enumerate  the  principal  causes  of  necrosis  of  the  jaws,  page  328 

4.  What  is  a  sequestrum?  page  335 

5.  Describe  the  treatment  of  necrosis  with  special  reference  to  the  removal  of  a 
sequestrum,  as  distinguished  from  the  so-called  carious  conditions,  pages  337,  338 

6.  How  may  necrosis,  resulting  from  the  effec's  of  mercury,  arsenic,  phosphorus, 
or  other  mineral  poisons,  syphilis,  tuberculosis,  exanthematous  diseases,  actinomycosis, 
glanders,  and  leprosy  be  diagnosticated?  pages  331-335 

FRACTURES  OF  THE  JAWS. 

1.  Define  the  term  fracture  as  applied  to  bones,  page  338 

2.  Name  varieties  of  bone  fractures,  pages  338,  339 

3.  Which  jaw  is  most  subject  to  fracture?  page  339 

4.  Give  the  diagnostic  indications  of  fracture,  page  340 

5.  Describe  the  methods  of  retaining  fractures  of  the  maxilloe  that  are  most  commonly 
employed,  pages  344,  345 

6.  Tell  ivhat  important  principle  must  govern  the  selection  of  a  method  of  retention 
in  the  treatment  of  fractures  of  the  jaws  and  give  these  as  nearly  as  possible  in  the 
order  of  their  importance,  page  344 

7.  Describe  the  repair  of  fractured  bones,  page  357 

8.  What  conditions  may  modify  the  time  required  for  complete  union?  page  357 

9.  What  complications  are  most  frequently  found  in  fractures  of  the  maxilloe? 
pages  358,  359 

AFFECTIONS  OF  THE   TEMPOROMANDIBULAR  ARTICULATION. 

1.  How  may  alterations  of  form  of  the  mandible  and  in  the  region  of  the  glenoid 
cavity  become  disturbing  factors?  page  360 

2.  Define  dislocation  or  luxation  of  a  joint,  page  360 

3.  Give  classification  of  dislocations  of  the  mandible,  page  361 


SELECTED  LIST  OF  EXAMINATION   QUESTIONS  711 

4.  Describe  the  diagnostic  symptoms  in  the  following  mandibular  dislocations: 
unilateral,  bilateral,  compound,  backward,  pages  362,  363 

5.  Describe  the  reduction  of  a  complete  bilateral  dislocation  of  the  lower  jaw?  page 
363.  364 

DISEASES  OF   THE   JOINTS. 

1.  Define  the  terms  synontis,  arthritis,  and  ankylosis,  pages  365,  366 

2.  Name  the  forms  of  ankylosis  of  the  lower  jaw,  page  366 

3.  Give  the  principal  causes  of  ankylosis,  pages  367,  368,  374 

4.  What  conditions  would  govern  the  treatment  to  be  advised  in-cases  of  temporary, 
fibrous,  and  bony  ankylosis?  pages  368,  369,  377 

5.  Give  prognosis  in  the  foregoing  cases,  pages  368,  369,  375 

6.  Describe  the  Murphy  operation  for  ankylosis  of  the  temporomandibular 
articulation,  pages  377,  381 

7.  Define  arthrodesis,  page  383 

RESECTIONS  OF  THE  JAWS. 

1.  For  what  purposes'  would  resection  of  the  jaws  be  recommended?  pages  393-400 

2.  Give  classification  of  the  forms  of  resections  of  the  jaws,  page  384 

3.  What  principles  must  be  borne  in  mind  in  undertaking  resection  of  the  jaws? 
384-387,  392-394 

DISEASES  OF   THE  SALIVARY   GLANDS. 

L  Tell  something  of  the  purposes  and  diagnostic  possibiUties  of  the  study  of 
saKva  as  undertaken  b}^  Michaels  and  Ivirk,  page  407 

2.  Describe  the  diagnostic  indications  of  anomaUes  and  injuries  of  the  saUvary 
glands  and  foreign  bodies  in  the  sahvary  glands,  pages  40S,  409 

3.  Describe  the  symptoms  and  treatment  of  sahvary  fistula,  page  409 

4.  Define  sialoUthiasis,  sialodochitis,  pages  411,  412 

5.  How  may  stones  in  the  saUvarj'  glands  or  their  ducts  be  .diagnosticated? 
page  412 

6.  Give  etiolog}',  sj-mptoms,  and  treatment  of  mumps,  pages  413,  414 

7.  What  danger  is  to  be  apprehended  from  metastatic  extensions  in  mumps? 
page  414 

8.  Define  aptyahsm,  page  417 

9.  Give  the  symptoms  and  most  common  causes  of  ptyalism,  page  417 
10.  What  are  the  symptoms  of  MikuUcz's  disease?  pages  418,  420 

DISEASES  OF  THE  LYMPH   GLANDS. 

1.  Describe  the  symptoms  of  adenoids  and  of  enlarged  tonsils,  page  421 

2.  Describe  suprahyoid  median  phlegmon,  page  426 

3.  Define  lymphadenitis,  page  426 

4.  Give  symptoms  of  Hodgkin's  disease,  page  429 

TUMORS. 

1.  Define  a  neoplasm,  page  431 

2.  Describe  the  distinguishing  characteristics  of  benign  and  malignant  tumors, 
page  434 

3.  Define  a  cyst,  pages  434,  435 

4.  Give  classification  of  cysts,  including  seven  varieties,  page  435 

5.  Define  the  term  ranula,  page  436 

6.  Give  the  etiology,  symptoms,  and  treatment  of  ranula,  page  437 

7.  Describe  periosteal  cysts  of  the  jaws,  proliferation  cysts,  multilocular  cysts, 
dermoid  cysts,  parasitic  cysts,  odontoma,  epithelial  odontoma,  follicular  odontoma  {or 
dentigerov^  cyst),  fibrous  odontoma,  cementome,  radicular  odontoma,  composite  odon- 
toma, compound  follicular  odontoma,  myxoma,  papilloma,  adenoma,  neuroma,  glioma, 
lipoma,  chondroma,  osteoma,  fibroma,  myoma,  angioma,  lymphangioma,  lymphoma, 
epulis,  pages  43^-468 


712  SELECTED  LIST  OF  EXAMINATION   QUESTIONS 

8.  Name  six  varieties  of  sarcoma,  page  468 

9.  Define  epulis,  page  468 

10.  Give  treatment  and  prognosis  in  cases  of  giant-celled  sarcoma,  pages  469-474 

11.  Give  prognosis  in  cases  of  carcinoma  and  sarcoma  under  usual  conditions, 
pages  469,  482 

12.  Why  is  it  important  to  treat  cases  in  the  precancerous  stage?  page  482 

DISEASES  OF  THE   MAXILLARY  SINUS. 

1.  What  relation  does  the  development  of  the  superior  maxillary  bone  bear 
to  nasal  diseases?  pages  495,  550 

2.  Describe  the  nasal  accessory  sinuses,  page  496 

3.  How  7nay  irregularities  of  the  upper  dental  arch  he  an  important  factor  in  caus- 
ing disease  of  the  maxillary  and  other  nasal  accessory  sinuses  through  pathological  nasal 
conditions?  page  497 

4.  Give  classifications  of  the  diseases  of  the  maxillary  sinus,  page  497 

5.  Describe  some  of  the  most  important  predisposing  and  exciting  causes  of 
maxillary  sinus  disease,  page  497 

6.  What  oral  factors  may  lead  to  empyema  of  the  maxillary  sinus?  page  499 

7.  Describe  t)ie  symptoms  of  empyema  of  the  maxillary  sinus,  page  505 

8.  What  diagnostic  indications  are  useful  in  examination  to  determine  the  existence 
of  diseased  conditions  of  the  maxillary  sinus,  and  which  may  be  relied  upon?  pages 
505-510 

9.  In  the  surgical  treatment  of  the  rnaxillary  sinus,  what  five  methods  may  be 
used?  page  510 

10.  Tell  the  differences  between  the  Kuster,  Caldwell-Luc,  Canfield-Ballenger, 
and  Denker  maxillary  sinus  operations,  pages  524-526 

11.  Describe  in  detail  a  radical  operation  for  the  cure  of  chronic  empyema  of 
the  maxillary  sinus,  according  to  the  Kuster  operation,  pages  513-518 

DISEASES  OF  THE  TONGUE. 

1.  Describe  glossitis,  page  531 

2.  Describe  the  indication  of  disease  that  may  be  noted  on  the  surface  of  the 
tongue,  page  532 

3.  Describe  aglossia,  lobulated  tongue,  microglossia,  macroglossia,  long  tongue, 
tongue-tie,  adherent  tongue,  pages  542-543 

HARELIP  AND   CLEFT  PALATE. 

1.  What  important  general  division  is  made  in  the  classification  of  cleft  palates? 
page  576 

2.  What  is  meant  by  congenital  and  acquired  clef t' palate?  page  576 

3.  Name  some  of  the  etiological  factors  that  may  be  important  in  leading  to  con- 
genital harelip  and  cleft  palate,  pages  577-581 

4.  Describe  the  most  common  for^ns  of  harelip  and  cleft  palate,  page  576 

5.  Describe  the  early  preparatory  treatment  of  an  infant  horn  with  harelip,  pages 
581,  591,  592 

6.  Define  cheiloplasty,  staphylorrhaphy,  uranorrhaphy,  uranoplasty,  urano- 
staphylorrhaphy,  pages  585,  621 

7.  Describe  the  distinctive  principles  of  five  different  types  of  surgical  operative 
methods  in  treatment  of  cleft  palate,  pages  622-624 

8.  What  are  the  objectionable  features  to  each  operation?  pages  625-627 

9.  Describe  the  modified  von  Langenbeck  operation  for  cleft  palate,  pages  637-639 

10.  What  conditions  govern  the  speech  results  after  surgical  closure  of  cleft  palate? 
pages  644-648 

11.  Describe  in  detail  the  ill  results  that  follow  closure  of  cleft  palate  in  early  infancy 
by  compression  to  force  the  sides  of  the  fissure  into  contact  and  passing  wiies  through 
the  upper  maxillae  to  hold  them  in  this  position,  pages  625-627,  647.  648 


INDEX. 


AuDUCENS  paralysis,  229,  230 
Abscess  of  brain,  221,  222 
Abscesses,  dento-alveolar,  14G 
diagnosis  of,  146 
etiology  of,  146 
exsection  of  roots  of  teeth  in, 

147 
treatment  of,  146 
Acapnia,  58 
Accessory  nerve,  spinal,  lesions  of,  302 

sinuses,  nasal,  495,  501 

pneumococcus  infection  of, 
504 

thyroid  tumors,  455 
Acinous  adenoma,  453 
Acquired  syphilis,  110 
Acromegaly,  321 
Actinic  rays  in  treatment  of  carcinoma, 

484 
Actinomycosis,  129 

agglutination  test  for,  132 

of  bone,  332 

diagnosis  of,  132 

etiology  of,  129 

of  mucous  membranes  of  mouth,  162 

pain  in,  130 

pathology  of,  129 

prognosis  of,  133 

of  salivary  glands,  420 

symptoms  of,  130 

of  tongue,  536 

treatment  of,  133 

sulphate  of  copper  in,  133 

trismus  in,  132 
Acupressure  in  hemorrhage,  39 
Adenia,  simple,  428 
Adenoid  cancer,  474 

vegetations.     See  Adenoids. 
Adenoids,  421 

etiology  of,  421 

exanthematous  fever  and,  421 

pharyngeal,  421 

symptoms  of,  421 

treatment  of,  423 
Adenoma,  452 

acinous,  453 

classification  of,  453 

differential  diagnosis  of,  455 

etiology  of,  454 

maUgnant,  475 

symptoms  of,  454 


Adenoma  of  tongue,  533 
treatment  of,  455 
tubular,  453 
Adherent  tongue,  545 
Adrenalin  in  hemorrhage,  41 
Agenesis,  320 
Agglutination  test  for  actinomycosis,  \.V2 

for  glanders,  135 
Aglossia,  542 

Alcohol,  injection  of,  in  trigeminal  neu- 
ralgia, 251 
technic  of,  251 
Alveolar   abscess,    disease   of    maxillary 
sinus  and,  500 
fracture  of  jaws,  339 
operation  for  disease  of  maxillary 

sinus,  510 
sarcoma,  468 
Amputation  neuromas,  457 
Amyehnic  neuromas,  457 
Amyotrophic  lateral  sclerosis,  201 
Analgesia,  17 

in  syringomyelia,  197 
Anemia  of  optic  nerve,  227 
Anesthesia,  17 

conductive,  20 
desirable  conditions  for,  32 
Gwathmey  apparatus  in,  33 
hyoscin-morphin  and,  34 
infiltration,  20 
intravenous,  29 

morphin  and  atropin  before,  34 
in  operation  for  cleft  palate,  630 
rectal,  29 

scopolamin-morphin  and,  34 
of  trigeminal  nerve,  237 
Anesthetics,  17 
general,  28 

chloroform,  29 
ether,  31,  33,  36,  37 
ethyl  chloride,  29 
nitrous  oxide  gas  and  oxygen, 
30 
oxide  -  oxygen  -  ether    se- 
quence, 31 
somnoform,  32 
local,  17-28 

apothesin,  19 
cocain,  19 
eucaine,  18 
novocain,  18 

quinine-urea  hydrochloride,  19 
Schleich's  infiltration,  20 
(713) 


714 


INDEX 


Anesthetics,  local,  scopolamin,   partial, 
foraged,  19 
stovain  and  novocain,  18 
principal,  17 

for  removal  of  impacted  teeth,  72 
Angina,  diphtheroid,  169 
Ludwig's,  168 
Vincent's,  169 
Angiomas,  462 
arterial,  463 
capillary,  462 
cavernous,  463 
diagnosis  of,  463 
plexiform,  463 
prognosis  of,  464 
treatment  of,  464 
Angioneurotic  edema,  316 
Angiosarcoma,  plexiform,  468 
Angle's  splint,  351 
Ankyloglossia,  543 
Ankylosis  of  jaws,  366 
bony,  374 

etiology  of,  374 
prognosis  of,  375 
symptoms  of,  375 
treatment  of,  377 

Esmarch's    operation, 

383 
Murphy's  operation  in, 

377 
postoperative,  383 
fibrous,  368 

diagnosis  of,  369 
etiology  of,  368 
pathology  of,  369 
prognosis  of,  369 
symptoms  of,  369 
treatment  of,  369 

postoperative,  371 
temporary,  367 

etiology  of,  367 
pathology  of,  367 
prognosis  of,  368 
symptoms  of,  368 
treatment  of,  368 
of  roots   of  teeth,   trigeminal   neu- 
ralgia and,  282 
Anoci-association,  38 
Anosmia,  227 
Anterior  pohomyelitis,  acute,  198 

chronic,  201 
Anthrax,  136 

diagnosis  of,  137 
etiology  of,  137 
intestinal,  137 
prognosis  of,  137 
symptoms  of,  137 
treatment  of,  137 
Antiseptics,  668 
Antitoxin,  tetanus,  93 
Antrum    of   Highmore.     See    Maxillary 

sinus. 
Aphthse,  Bednar's,  156 
Aphthous  stomatitis,  155 
Apothesin  in  local  anesthesia,  19 


Aptyahsm,  417 
Argyria,  172 
Arsenic  for  syphilis,  127 
Arsenical  necrosis  of  bone,  334 
pathology  of,  334 
symptoms  of,  335 
treatment  of,  335 
Arterial  angiomas,  463 
Arthritis,  365 
Arthrodesis,  383 
Aseptic  fever,  84 

wound  fever,  84 
Astomia,  573 
Ataxia,  Friedreich's,  212 

locomotor,  211 
Atrophic  paralysis,  chronic.     See  Polio- 
myelitis, anterior,  chronic, 
spinal  paralysis,  acute,     ^'ee  Polio- 
myeUtis,  anterior. 
Atrophy  "of  bone,  318 
concentric,  318 
eccentric,  318 
pressure,  319 
muscular,  in  syringomyelia,  198 
of  optic  nerve,  228 
progressive    muscular.     See    Polio- 
myelitis, anterior,  chronic, 
of  tongue,  535 
Auditory  nerve,  lesions  of,  299 
"Aura"  in  tic  douloureux,  246 
Autogenous  bacterins  in  septic  fever,  90 


B 


Bacillus  of  tetanus,  90 

of  tuberculosis,  94 
Bacteriemia,  83 

Bacterins,  autogenous,  in  septic  fever,  90 
Bandaging  for  avoidance  of  shock,  57 
Barlow's  disease,  185 
Beck's  paste,  519 
Bednar's  aphthse,   156 

treatment  of,  156 
Bifid  tongue,  542 
Bilateral  harelip,  576 

parotid  tumors,  417 
Blastomycosis  cutis,  190 
BUsters,  fever,  179 

Blood,    transfusion   of,    in   hemorrhage, 
direct,  41 
indirect,  43 

technic  of,  46 
Bone,  actinomycosis  of,  332 
atrophy  of,  318 
caries  of,  326 
diseases  of,  318 
hypertrophy  of,  320 
inflammation  of,  326 
leprosy  of,  333 
malformation  of,  319 
necrosis  of,  326 
arsenical,  334 
mercurial,  333 
phosphorus,  334 


INDEX 


715 


Bone,  regeneration  of,  319 
syphilis  of,  332 

tuberculosis  of,  331  1 

periosteal,  332  I 

Bonnecken's  artificial  jaw,  390 
Brain,  abscess  of,  221 

basal    disease    of,    facial    paralysis 
and,  293  j 

diseases  of,  215 
tumor  of,  222 

complete  report  of  case  of,  222 
Brewer's  glass  cannula  for  transfusion,  43 

method  of  transfusion  of  blood,  42 
Bridge-work,  improper,  trigeminal  neu- 
ralgia and,  286 
Brophj-'s  method  of  wiring  in  operation 

for  cleft  palate,  621 
Brown's  clamp  for  surgical  treatment  of 
harelip,  598,  599 
gag  for  cleft  palate,  630,  631 
knife  for  cleft  palate,  641 
method  of  treatment  of  ranula,  437 
operation  for  cleft  palate,  628,  630- 
638 
for  double  harehp,  605,  606 
for  harehp,  598^604 

closure  of  hp  fissure  in,  591 
of  immediate  surgical  separa- 
tion   of    superior    maxiUary 
bones  to  widen  the  nares  for 
improvement  of  respiratorj', 
and  other  conditions,  556 
periosteal  elevator  for  cleft  palate, 
633,  640,  641 
Bubo,  chancroid  and,  128 
Bulbar  palsy,  224 
Burns  and  scalds,  174 
Burrie's    method    of    identification    of 
Spirocheta  palUda,  121 


CALcrLi,  sahvary.     See  Salivary-  stones. 
Caldwell-Luc    operation   for   disease   of 

maxillary  sinus,  519 
Cancer.     See  Carcinoma. 
Cancrum  oris.     See  Stomatitis,  gangren- 
ous. 
Canfield-Ballenger  antrum  operation  for 

disease  of  maxillary  sinus,  522-524 
Cannula,  transfusion.  Brewer's  glass,  43 

Crile's,  42 
Capillary  angiomas,  462 
Carbon  dioxide  content  of  blood,  shock 

and,  57,  58 
Carcinoma,  474 

of  cheek,  treatment  of,  490 
colloid,  476 
diagnosis  of,  480 
epithehal,  474 
etiologj^  of,  476 
gelatiniform,  476 
glandular,  476 
of  jaw,  treatment  of,  490 


Carcinoma  of  lips,  treatment  of,  485 
location  of,  477 
melanotic,  476 
mucoid,  476 

of  palate,  treatment  of,  490 
prognosis  of,  482 

in  region  of  maxillary  sinus,  treat- 
ment of,  490 
symptoms  of,  478 
of  tongue,  542 

treatment  of,  489 
treatment  of,  482 

actinic  rays  in,  484 
burning  in,  485 
dried  thymus  gland  in,  483 
drugs  in,  484 
enzj'me,  483 
extirpation  in,  485 
Finsen  hght  in,  484 
hquid  air  in,  484 
operative,  485 
racUum  in,  483 
thj'roid  extract  in,  483 
ultra\'iolet  rays  in,  484 
x-rays  in,  484" 
Caries  of  bone,  treatment  of,  336 

of  jaw,  326 
Carious  teeth,  trigeminal  neuralgia  and, 

286 
Carotid,  external,  hgation  of,  in  hemor- 
rhage from  wounds  of  mouth,  80 
Carrel's   sodium   h5'pochlorite   solution, 

669 
Castor   oil   in   treatment   of   trigeminal 

neuralgia,  249 
Catarrh  of  mucous  membrane  of  mouth, 

155 
Catarrhal  maxillary  sinuitis,  acute,  497 

chronic,  437 
Cavernous  angiomas,  463 

hemangioma  of  tongue,  540 
lymphangioma  of  tongue,  542 
Cellulitis,     diffuse     submaxillary.       See 

Ludwig's  angina. 
Cementome,  446 
Cephahc  tetanus,  92 
Cephahtis,  217 
Cerebral  axis,  diseases  of,  224 
diseases,  215 
embohsm,  215 
hemorrhage,  215 
meningitis,  218 
spastic  paralysis,  215 
thrombosis,  215 
Cerebrospinal  meningitis,  epidemic,  218 
Chancre,  116 
hard,  116 
Himterian,  116 
indurated,  116 
of  Up,  116 

soft.     See  Chancroid, 
of  tongue,  116 
Chancroid,  127 

bubo  and,  128 
'  diagnosis  of,  128 


716 


INDEX 


Chancroid,  etiology  of,  128 
•mixed  sore  and,  128 
prognosis  of,  128 
symptoms  of,  128 
treatment  of,  128 
Cheiloplasty.     See    Harelip,    treatment 

of,  surgical. 
Chin,  receding,  operation  for,  400 
Chondroid,  458 

exostosis,  458 
Chondromas,  458 
etiology  of,  458 
prognosis  of,  459 
symptoms  of,  458 
treatment  of,  459 
Chondrosarcoma,  468 
Chloroform  in  general  anesthesia,  23 
"Choked  disk,"  227 
Chorea,  304 

etiology  of,  304 
prognosis  of,  305 
symptoms  of,  305 
treatment  of,  305 
Circumscribed  glossitis,  531 
Clamp,  Brown's  for  surgical  treatment 

of  harelip,  598,  599 
Cleft  palate,  576.     See  also  Harelip. 
Friedreich's  ataxia  and,  212 
harehp  without,  treatment  of, 

609 
operation  for,  620 

access  to  field  of,  630 
aluminum  plates  in,  627 
anesthesia  in,  630 
Brophy's   method  of  wir- 
ing in,  621 
Brown's,  628,  629-639 
changes  in  form  after,  639 
choice  of,  628 
compression  in,  622,  625 

disadvantages  of,  625 
Davies-Colley,  624 
essentials  of,  628 
Ferguson's  method  in,  623 
flaps  in,  anterior  ends  of 
detaclmaent  of,  623 
inversion  of,  disadvan- 
tages of,  626 
mucoperiosteal,  623 
turning  over  of,  622 
fracture    of    palate    bones 

in,  622 
gag  for,  author's,  630,  631 
incision    in,    for    rehef    of 

tension,  633 
knife  for,  author's,  641 
Lane's  method  in,  622 
methods   of   retention   in, 

627 
muscular      alignment     in, 

644 
needles  for,  638,  640,  641 
periosteal      elevator     for, 

author's,  633 
position  of  patient  for,  629 


Cleft  palatj,  operation  for,  preservation 

of  blood  supply  in,  632 

retention  appliances  in,  624 

sutures   in,    624,  635, 

636 

rubber  plates  in,  627 

separation     of     mucoperi- 

osteum  in,  637 
speech  results  after,  644 
phonograpliic   records 
of,  650 
sutures  for,  634 

retention,  621,  635, 636 
transplantation    of    tissue, 

in,   627 
types  of,  622 
speech  defects  and,  conditions 
governing,  646 
correction  of  deformity 
of  dental  arch, 
and,  649 
operative,  650 
due    to    early    opera- 
tions, 647 
to    flexibihty    of 

tissues,  648 
to  insufficient  vel- 
um, 648 
to  nasal  maldevel- 

opment,  648 
to    postoperative 
imperfection,647 
to    shortening   of 
hard  palate, 648 
etiological  factors  in- 
fluence of,  646 
improvement  of,  648 
reconstruction  of  deformed 
hps  and,  649 
treatment  of,  surgical,  620 
wide,  reduction  of,  by  maxil- 
lary operation,  628 
Cocain  in  local  anesthesia,  18 
Cold  abscess,  332 

in  hemorrhage,  40 
shock  and,  53 
CoUes'  law  in  hereditary  syphilis,  107 
Colloid  carcinoma,  476 
Coloboma  of  face,  575 
Columnar-cell  epithehoma,  475 
CompUcated  wounds,  76 
Compression  in  operation  for  cleft  palate, 

622,  625 
Conductive  anesthesia,  20 
Congenital  cystic  hygroma,  464 
Connective-tissue  tumors,  adult,  457 
Contracted  nares,  treatment  of,  550 
Con\ailsions,  303 

eruption  of  teeth  and,  303 
etiology  of,  303 

pathological  dentition  and,  304 
Copper,    sulphate   of,   in    treatment   of 

actinomycosis,  133 
Coryza,  acute,  disease  of  maxillary  sinus 
and,  497 


INDEX 


717 


Coxalgiia,  332 

Cranial  nerve,  diseases  of,  226 

eighth.     See  Auditory  nerve, 
eleventh.    See  Spinal  accessory 

nerve, 
fifth.     See  Trigeminal  nen'e. 
first.     See  Olfactory  nerve, 
fourth,  lesions  of,  229 
ninth.     See     Glossopharyngeal 

nerve, 
second.     See  Optic  nerve, 
seventh.     See  Facial  ners'e. 
sixth,  lesions  of,  229 
tenth.     See  Vagus  nerve, 
third,  lesions  of,  229 
twelfth.   See  Hji^oglossal  nerve. 
Crile's  method  of  transfusion  of  blood, 
41,  42 
transfusion  cannula,  42 
Cn,-ptogenetic  septic  fever,  85 
Cushing's  operation  for  removal  of  Gas- 

serian  ganglion,  269,  270,  272 
Cutaneous  horns,  4.51 

test,  von  Pirquet's,  for  tuberculosis, 
100 
Cylindric-cell  epithelioma,  474 
Cystic  hygroma,  congenital,  464 
Cysticercus  cysts  of  tongue,  537 
Cj'stocele  of  maxiUarj-  sinus,  529 
Cystomas,  434 

classification  of,  435 
Cysts  of  base  of  tongue,  537 
dentigerous,  445 
dermoid,  442 
echinococcus,  444 
of  glands  of  Blandin-Xuhn,  436 
of  maxillar>^  sinus,  497,  529 
of  mucous  glands,  435 
multilocular,  441 
parasitic,  444 
periosteal,  439 
proliferation,  441 
retention,  435 
of  salivar>-  glands,  420 
sublingual,  436 
thjToglossal,  538 
of  tongue,  536 


Dactylitis,     hereditarv    sj-philis    and, 

109 
Dakin's  solution,  668 
Da^-ies-Colley's  operation  for  cleft  palate 

624 
Denker  operation  for  disease  of  maxiUarj' 

sinus,  521 
Dental   arch,    deformed,    correction   of, 
improvement    of    defects    of 
speech  after,  649 
irregularity  of,  surgical   treat- 
ment of  harelip  and,  588 
aspects  of  trigeminal  neuralgia,  275 
cysts,  maxillarj'  sinus  and,  529 


Dental  factors  of   trigeminal    neuralgia, 
281-292 
origin  of  disease  of  maxillary  sinus, 

499,  500 
pulp,  diseases  of,  282 

trigeminal   neuralgia    and, 
283 
Dentigerous  cysts,  445 

maxillary  sinus  and,  529 
symptoms  of,  445 
Dentition,  pathological,  59 

convulsions  and,  304 
diagnosis  of,  62 
in  adults,  62 
differential,  62 
in  infants,  62 
etiologj'  of,  59 
extraction  of  teeth  in,  70 
preservation  of  teeth  in,  70 
sjTnptoms  of,  60 
general,  61 
local,  60 
treatment  of,  62 
in  adults,  66 
in  infants,  62 
palliative,  70 
Dento-alveolar  abscesses,  146 
diagnosis  of,  146 
etiology  of,  146 
exsection  of  roots  of  teeth  in, 

147 
treatment  of,  146 
Dermoid  cysts,  442,  443 
prognosis  of,  444 
sjTnptoms  of,  442 
of  tongue,  537 
Development,      imperfect,      defects    of 

speech  due  to,  653 
Diffuse  suppuration  of  floor  of  mouth. 

See  Lud^ig's  angina. 
Diphtheroid  angina,  169 
etiologj'  of,  169 
treatment  of,  169 
Direct  transfusion  of  blood  in  hemor- 
rhage, 41 
Disarticulation  of  jaw,  389 
Disk,  choked,  227 
Dislocations  of  jaws,  360         * 
bilateral,  361 
chronic,  364 

etiology  of,  365 
treatment  of,  365 
classification  of,  361 
compHcated,  361 
compound,  361 
diagnosis  of,  363 
etiology  of,  361 
forward,  361 
incomplete,  361 
pathology  of,  362 
simple,  361 
symptoms  of,  362 
treatment  of,  363 
unilateral,  361 
Double  harelip,  576 


718 


INDEX 


Double  harelip,  treatment  of,  604 

Dry  mouth,  417 

Duchenne  type  of  muscular  dystrophies, 

204 
Duct,  salivary,  fistula  of,  409 
injuries  of,  408 
Steno's,  407 
Wharton's,  407 
Dystrophies,  muscular,  203 

analysis  of  cases  of,  205-210 
Duchenne  type,  204 
Erb  type,  204 
etiology  of,  203 
Landouzy-Dejerine  type,  204 
prognosis  of,  204 
symptoms  of,  203,  204 
"tapir  mouth"  in,  204 
treatment  of,  204 
syphilitic,  114 


E 


EcHiNococcus  cysts,  444 

of  tongue,  537 
Eczema,  182 

labiaHs,  183 
Edema,  angioneurotic,  316 

of  optic  nerve,  227 
Eighth    cranial    nerve.     See    Auditory 

nerve. 
Elephantiasis  congenita  mollis,  464 

grecorum.     See  Leprosy. 
Elevator,  Brown's  periosteal,  for  opera- 
tion for  cleft  palate,  638,  640,  641 
Eleventh     cranial     nerve.     See     Spinal 

accessory  nerve. 
Embolism,  cerebral,  215 
Empyema,  chronic,  of  maxillary  sinus, 
497 

disease  of  maxillary  sinus  and,  503 

latent,  diagnosis  of,  from  disease  of 
maxillary  sinus,  506 

simple,  diagnosis  of,  from  disease  of 
maxillary  sinus,  506 
Encapsulated  lipomas,  457 
Encephahtis,  217 
Enchondroma,  458 
Enchondrosis,  458 
Encystment  of  teeth,  61 
Endemic  meningitis,  218 
Endothelioma,  468 

of  tongue,  542 
Enostosis,  459 

Epidemic  cerebrospinal  meningitis,  218 
Epilepsy,  306 

dental  irritations  and,  308-310 

etiology  of,  307 

fenestration  of  skull  for,  309 

grand  mal,  307 

pathology  of,  307 

petit  mal,  307 

symptoms  of,  307 

treatment  of,  307 
Epileptiform  neuralgia,  240 


Epipharyngeal  tonsils.     See  Adenoids. 
Epithelial  carcinoma,  474 

odontoma,  444 

tumors,  adult,  444 
Epithelioma,  474 

cylindric-cell,  474 

squamous,  474 

syphilis  and,  119 

tubulated,  474 
Epulis,  468 

diagnosis  of,  469 

etiology  of,  468 

prognosis  of,  469 

symptoms  of,  468 
Erb  type  of  muscular  dystrophies,  204 
Eruption  of  teeth,  59 
Erysipelas,  190 

ambulans,  191 

migrans,  191 

of  mucous  membrane  surfaces,  191 

neonatorum,  191 

phlegmonous  glossitis  and,  533 
Erythema,  177 

endemicum,  178 

multiforme,  177 

pellagrosum,  178 

sjTnptomatic,  177 
Esmarch  bandage  in  hemorrhage,  39 
Ether  in  general  anesthesia,  31 
Ethmoidal  sinus,  501 
Ethyl  chloride  in  general  anesthesia,  29 
Eucain  in  local  anesthesia,  18 
Excitement,  shock  and,  53 
Exostosis,  chondroid,  458 
Exposure,  facial  paralysis  and,  293 
Exsection  of   roots  of   teeth  in  dento- 

alveolar  abscesses,  147 
Extracranial  operations  at  base  of  skull 
in  treatment  of  trigeminal  neuralgia, 
268 


Face,  coloboma  of,  575 

deformities  of,  permanent,  in  early 

treatment  of  harelip,  583 
fissure  of,  574 
gunshot  wounds  of,  688 
hemiatrophy  of,  233 
hemihypertrophy  of,  322 
Facial  nerve,  anatomical  relation  of,  292 
lesions  of,  292 
paralysis,  293 
spasm,  306 

diagnosis  of,  from  tic,  306 
Farcy,  134.     See  also  Glanders. 
Fatty  tumor,  457 
Female  generative  organs,  pathological 

affections  of,  harehp  and,  581 
Fenestration  of  skull  for  epilepsy,  309 
Ferguson's  method  in  operation  for  cleft 

palate,  623 
Ferment  fever,  84 
Fever,  84 

aseptic,  84 


INDEX 


719 


Fever,  aseptic  wound,  84 
blisters,  179 
ferment,  84 
resorption,  84 
septic,  85 

splenic.     See  Anthrax, 
traumatic,  84 
Fibromas,  460 

etiolofry  of,  460 
prognosis  of,  460 
symptoms  of,  460 
of  tongue,  539 
treatment  of,  461 
Fibrous  odontoma,  445 
Fifth    cranial    nerve.     See    Trigeminal 

nerve. 
Finsen  light  in  treatment  of  carcinoma, 

484 
First  cranial  nerve.     (5ee. Olfactory  nerve. 
Fischer's  formula  for  infiltration  anes- 
thesia, 20 
Fissure  of  face,  574 
of  jaw,  574 
of  lower  hp,  574 
Fistula,  salivary,  409 
Flesh  wounds,  76 
Focal  infection  of  oral  origin,  142 
Follicular  odontomas,  441,  445,  448 
Foot-and-mouth  disea.se,  160 

tongue  in,  536 
Forcipressure  in  hemorrhage,  39 
Foreign  bodies  in  maxillary  sinus,  497, 
528 
phlegmonous  glossitis  and,  533 
in  salivary  ducts,  410 
Fournier's  teeth,  109 
Fourth  cranial  nerve,  lesions  of,  229 
Fractures  of  jaws,  338 
alveolar,  339 
bandages  in,  355,  356 
complete,  338 

comminuted,  338 
comphcated,  338 
compound,  338 
impacted,  339 
multiple,  338 
simple,  338 
compUcations  of,  358 
diagnosis  of,  340 
etiology  of,  339 
fixation  in,  347 
gimshot,  339,  688 
incomplete,  339 
depressed,  339 
fissured,  339 
green-stick,  339 
indented,  339 

perforating,  339 
punctured,  339 
infected,  operation  on,  682 
intra-uterine,  339 
pathological,  339 
reduction  of,  345 
repair  of,  357 
subperiosteal,  339 


Fractures  of  jaws,  symptoms  of,  340 

transverse,  341 

treatment  of,  344 

union  in,  complete,  357 
delayed,  358 
faulty,  358 

varieties  of,  338 

in  war  wounds,  679 
Friedreich's  ataxia,  212 

cleft  palate  and,  212 

harelip  and,  212 
Frog  tongue,  436 
Frontal  sinus,  501,  502 
Furring  of  tongue,  531 


G 

Gag,   Brown's,  for  operation   for   cleft 

palate,  630,  631 
Ganghon,  Gasserian,  232,  235,  237,  284 
Ganghonic  neuromas,  457 
Gangrene  of  tongue,  535 
Gangrenous  stomatitis,  157 
Gas-producing  organisms,  infection  by, 

667 
Gasserian  ganglion,  232,  235,  237,  284 
Hartel  method  of  injecting,  254 
removal  of,  269 

Gushing' s    operation    for, 

269,  272 
Hartley-Krause    operation 

for,  269,  270 
indications  for,  269 
mortahty  in,  277,  278 
transzygomatic  route  for, 

270 
in  treatment  of  trigeminal 
neuralgia,  269 
in  trigeminal  neuralgia,  243 
Gelatiniform  carcinoma,  476 
Gelsemium  in  treatment   of  trigeminal 

neuralgia,  249 
Geographical  tongue,  531 
Giant-cell  sarcoma,  468 
■Gingivitis,  interstitial,  151 

diagnosis   of,    from   disease   of 

maxillary  sinus,  508 
etiology  of,  151 
symptoms  of,  152 
treatment  of,  152-154 
marginal,  151 
Glanders,  134,  333 

agglutination  test  for,  135 
diagnosis  of,  135 
etiology  of,  134 
mallein  in,  135 

of  mucous  membranes  of  mouth,  167 
pathology  of,  134 
Strauss's  test  for,  135 
S3rmptoms  of,  135 
of  tongue,  536 
treatment  of ,''136 
Glands  of  Blandin-Nuhn,  cysts  of,  436 
mucous,  cysts  of,_436 


720 


INDEX 


Glands,  salivary,  diseases  of,  407 

fistula  of,  409 
Glandular  carcinoma,  474 
Gliomas,  457 

Glossis  spinalis.     See  Syringomyelia. 
Glossitis,  531 

chronic,  532 

leukoplakia  and,  532 
syphilis  and,  532 
circumscribed,  531 
diagnosis  of,  532 
interstitial,  533 
phlegmonous,  533 

erysipelas,  and,  533 
etiology  of,  533 
foreign  bodies  and,  533 
symptoms  of,  533 
treatment  of,  534 
pseudomembranous,  535 
treatment  of,  534 
Glossopharyngeal  nerve,  lesions  of,  301 
Goiter,  lingual,  539 
Gonorrheal  ulceromembranous  cellulitis, 

171 
Grand  mal,  307 

Green-stick  fractures  of  jaws,  339 
Gumma,  syphilis  and,  119 

of  tongue  in  syphilis,  119 
Gums,  inflammation  of.     See  Gingivitis. 
Gunning's  interdental  splint,  347 
Gunshot  fractures  of  jaws,  339,  688 
Gwathmey  apparatus  for  general  anes- 
thesia, 33 


Habit  spasm  of  trigeminal  nerve,  235 
Halisteresis,  318 
Hammond's  splint,  353 
Hard  chancre,  116 
Harelip,  576 

acquired,  576 
age  and,  576 
bilateral,  576 
character  of,  576 
classification  of,  576 
congenital,  576 
double,  576 

Brown's  operation  for,  605-609 
dressings  for,  606 
postoperative    control 

strips  for,  606 
technic  of,  605-607 
treatment  of,  604 
etiology  of,  577 
family  histories  of,  580 
female  generative  organs  and,  581 
form  of,  576 

Friedreich's  ataxia  and,  212 
hereditary  tendency  and,  579 
heredity  and,  direct,  579 
hypophysis  and,  581 
incision  for,  author's,  600 
maternal  impressions  and,  579 
metabolism  and,  579 


Harelip,  position  of  child  in  utero  and, 
580 
operation  for,  author's,  597,  598-600 
excessive  size  of  lip  after,  cor- 
rection of,  614 
excision     of     excessive     tissue 

after,  614 
imperfect  closure  of  Up  fissure 

after,  correction  of,  611 
lip  defects  after,  correction  of, 

610 
nose  defects  after,  correction  of, 

610 
removal  of  scars  after,  610 
situation  of  scar  after,  620 
unequal  height  of  lip  borders 

after,  correction  of,  612 
unsightly  cartilage  of  nose  after, 

correction  of,  619 
V-shaped  notch  at  lower  border 
of    lip    after,    correction  of, 
611 
treatment  of,  early,  in  infants,  531 
deformities    of    face    and, 

permanent,  583 
disadvantages  of,  581-583 
effect  of,  upon  speech,  585 
failure  of,  585 
mortality  and,  583 
nasal  stenosis  and,  584 
toxemia  and,  583 
surgical,  585 

asymmetry  from,  586 
author's  method   of,    591, 

604 
clamp    for,    authors,    598, 

599 
closure  of  lip  fissure,  591 
compression  of  vessels  in, 

599 
deformity  from,  586 
difficulties  of,  586 
hemorrhage  in,  control  of, 

599 
incisions  in,  author's,  600 
irregularity  of  dental  arch 

and,  588 
maldevelopment  and,  587 
nasal  deformity  and,  587 
operative  defects  and,  588 
principles  of,  585 
spUnt    and    wire    tension 

suture  in,  598 
sutures  in,  author's,  601 
tension  and,  586 
zinc  oxide   adhesive   strip 
in,  592 
without  cleft  palate,  treatment  of, 
609 
Hartel   method   of   injecting    Gasserian 

ganglion,  254 
Hartley-Krause   operation   for   removal 

of  Gasserian  ganglion,  270 
Headache  in  affections  of  sensory  portion 
of  trigeminal  nerve,  238  '^ 


INDEX 


721 


Healing  by  adhesion  of  granulating  sur- 
faces, 77 
hy  first  intentit)n,  77 
by  granulation,  77 
by  immediate  union,  7() 
by  second  intention,  77 
by  third  intention,  77 
Heat  in  hemorrhage,  39 
Hemangioma  of  tongue,  540 
Hematogenous  pigmentation,  172 
HemiatrDi^hy  of  face,  233 
Hemiglossitis,  535 
Hemiiiypertrophy  of  face,  322 
Hemiplegia,  215 

Hemophilia,  treatment  of,   by  transfu- 
sion, 49 
Hemorrhage,  38 

acupressure  for,  39 
adrenaUn  in,  41 
cerebral,  215 
classification  of,  38 
control  of,  cold  for,  39 

in  wounds  of  mouth,  77 
Esmarch  bandage  for,  39 
etiology  of,  38 
forcipressure  for,  39 
forms  of,  38 
grave,  40 

internal  medication  for,  40 
treatment  of,  40 
heat  for  control  of,  39 
hypodermoclysis  for,  39,  41,  48 
intravenous  infusion  for,  39,  47 
method  of,  47 
of  normal  salt  solution  in, 
47 
ligation  for,  39 
pituitary  extract  in,  41 
position  in,  40 
proctoclysis  for,  39,  49 
shock  and,  54 
styptic  for,  39 
symptoms  of,  39 
tourniquet  for,  39 
transfusion  of  Vilood  for,  39,  41 
Brewer's  method  of,  42 
Crile's  method  of,  41,  42 
direct,  41 
indirect,  43 

technic  of,  46 
Ottenberg's  method  of,  42 
Percy's  method,  43 
treatment  of,  39 
under  periosteum,  324 
Hepatogenous  pigmentation,  173 
Hereditarj  syphilis,  107 
Heredity,  direct,  harelip  and,  578 
Herpes  facialis,  179 
simplex,  179 

zoster,  paralysis  of  trigeminal  nerve 
and,  235 
Highmore,    antrum    of.     See    Maxillary 

sinus. 
Hodgkin's  disease,  428,  466 
etiology  of,  428 
46 


Hodgkin's  disease,  prognosis  of,  429 

treatment  of,  429 
Hunterian  chancre,  116 
Hutchinson's  teeth,  108 
Hydatid  cysts  of  tongue,  537 
Hyoscin-morphin,  anesthesia  and,  34 
Hyi^ercementosis,    trigeminal    neuralgia 

and,  281 
Hyperemia  of  optic  nerve,  227 
Hyperesthesia  of  trigeminal  nerve,  236 
Hyi^ersecretion  from  salivary  glands,  417 
Hyperthermia,  84 
Hypertonic  and  isotonic  salt  solutions, 

671 
Hypertrophy  of  bone,  320 
Hypodermoclysis  in  hemorrhage,  39,  48 

in  septic  fever,  86 
Hypoglossal  nerve,  lesions  of,  302 

paralysis  of,  302 
Hypophysis,  hareUp  and,  581 
Hysteria,  313 

diagnosis  of,  314 

etiology  of,  313 

symptoms  of,  313 


Immunity  to  syphiUs,  112 
Impacted  teeth,  61-65 

irritation   of   trigeminal   nerve 

and,  235 
removal  of,  70 

anesthetics  for,  72 
asepsis  in,  73 

exposure      of      embedded 
tooth  crown  in,  76 
Indirect  transfusion  of  blood  in  hemor- 
rhage, 43 
Indurated  chancre,  116 
Infantile    paralysis.     See    Poliomyelitis, 
anterior, 
scorbutus,  185 
sialoadenitis,  415 
Infants,  early  treatment  of  harehp  in,  581 
Infected  fractures,  operation  on,  667 
Infection,  82 

by  gas-producing  organisms,  667 
focal,  of  oral  origin,  142 
shock  and,  53 
Infectious  diseases,  82 

of  maxillary  sinus,  497,  528 
Inferior  maxillary  nerve,  operation  for 

exposure  of,  265-268 
Infiltration  anesthesia,  20 
Fischer's,  20 
Schleich's,  20 
technic  of,  20 
Inflammation  of  bone,  326 
Inframaxillary  operation  for  removal  of 

tongue,  489 
Infraorbital  nerve,  exposure  of,  at  infra- 
orbital foramen,  263 
operation  for  exposure  of,  260 
Infusion,  intravenous,  in  hemorrhage,  39, 
47 


722 


INDEX 


Interdental  splints,  347-349 
Interstitial  gingivitis,  151 

glossitis,  533 

neuritis,  pathology  of,  193 
Intestinal  tuberculosis,  95 
Intoxication,  putrid,  82 

septic,  82 
Intracranial  pressure,  215 
Intracystic  villous  papilloma,  450 
Intranasal    examination    in    disease    of 
maxillary  sinus,  508 

operation  for  disease  of  maxillary 
sinus,  511 
Intra-uterine  fractures  of  jaws,  339 
Intravenous  anesthesia,  29 

infusion  in  hemorrhage,  39,  47 
Inunction  test  for  tuberculosis,  101 
lodism,  syphilis  and,  126 
Isotonic  salt  solution,  671 


Jaw  grinding,  trigeminal  neuralgia  and, 

280 
Jaws,  ankylosis  of,  366 
caries  of,  326 
disarticulation  of,  389 
dislocations  of,  360-365 
fissure  of,  574 
fixation    of,  in    injuries  of   salivary 

glands,  408 
fractures  of,  338 

infected,  operation  on,  682 
in     war     wounds,      American 
Ambulance    method    of 
treatment,   679 
frequency  of,  673 
necrosis  of,  326 

prognathous  lower,  reduction  of,  401 
resection  of,  for  cosmetic  purposes, 
396 
of  lower,  384 
of  upper,  393 
Joints  in  hereditary  syphihs,  109 


Keloid,  460 

Kingsley's  interdental  splint,  347 
palatograms,  655 

Knife,  author's,  for  operation  for  cleft 
palate,  641 

Kocher's     operation     for     removal     of 
tongue,  489 

Kopf  tetanus,  92 

Krause's  operation  for  trigeminal  neu- 
ralgia, 262,  263 

Kuster  operation  for  disease  of  maxillary 
sinus,  513 


Landouzy-Dejerine  type  of  muscular 
dystrophies,  204 


Landry's  paratysis,  211 

Lane's   method   in   operation    for    cleft 

palate,  622 
Lateral  sclerosis,  amyotrophic,  201 
Leontiasis  ossea,  322 

treatment  of,  323 
Lepra.     See  Leprosy. 
Leprosy,  139 

of  bone,  333 
etiology  of,  139 

of  mucous  membrane  of  mouth,  1()8 
symptoms  of,  139 
of  tongue,  536 
Leukemic  stomatitis,  162 
Leukokeratosis  buccahs,  181 
Leukoma,  181 
Leukoplakia,  181 
buccaUs,  181 
chronic  glossitis  and,  532 
etiology  of,  181 
pathology  of,  181 
prognosis  of,  182 
symptoms  of,  182 
in  syphihs,  118 
treatment  of,  182 
Leukoplasia,  181 
Lichen  planus,  179 

symptoms  of,  179 
Ligation  in  hemorrhage,  39 
Lingua  dissecata,  543 
frenata,  543 
pUcata,  543 
Lingual  goiter,  539 

diagnosis  of,  539 
etiology  of,  539 
symptoms  of,  539 
treatment  of,  539 
Lip   borders,   unequal  height   of,    after 
operation  for  harehp,   correction 
of,  611 
chancre  of,  116 
defects  after  operation  for  harelip, 

correction  of,  610 
deformed,    correction   of,    improve- 
ment of  defects  of  speech  after, 
649 
excessive  size  of,  after  operation  for 

hareUp,  correction  of,  614 
fissure  of,  574 
imperfect  closure  of,  after  operation 

for  harehp,  correction  of,  610 
lower  border  of,  V-shaped  notch  at, 
after  operation  for  harehp,   cor- 
rection of,  611 
lymphangioma  of,  573 
maKormations  of,  573 
Lipodystrophy,  progressive,  317 
Lipomas,  457 
difTuse,  457 
encapsulated,  457 
etiology  of,  457 
prognosis  of,  458 
symptoms  of,  457 
of  tongue,  538 
treatment  of,  458 


INDEX 


723 


Lol)ulafcd  tongue,  542 
Local  anesthetics,  18 
Lockjaw.     See  Tetanus. 
Locomotor  ataxia,  211 
Loher's  splint,  352 
Ludwig's  angina,  1G8 

etiology  of.  168 
treatment  of,  169 
Lumpy  jaw.     See  Actinomycosis. 
Lupus  execlens,  47G 
Lymph  glands,  oral,  diseases  of,  421 

nodes,  oral,  diseases  of,  421 
in  syphilis,  116 

hereditary,  116 
tumors  of,  430 
Lymphadema,  42S 
Lymphadenitis,  426 

etiology  of,  426 

symptoms  of,  427 

treatment  of,  427,*428 

x-rays  and,  428 
Lymphadenoid  hyperplasia,  progressive, 

428 
Lymphadenoma,  428,  466 

malignant,  428 
Lymphangioma,  430,  464 

cavernous,  430 

of  lips,  573 

sjTiiptoms  of,  465 

of  tong-ue,  541 

treatment  of,  465 
Lymphangitis.     See  Lymphadenitis. 
Lymphatic  dilatation,  430 

nevi,  430 
Lymphoma,  466 

malignant,  428 
Lymphosarcoma,  428 


M 


Macrocheilia,  430,  465,  573 

Macroglossia,  430,  464 

Macrostomia,  573 

Maldevelopment,  surgical  treatment  of 

harelip  and,  587 
Malformation  of  bone,  319 

of  tongue,  542 
Malignant  lymphadenoma,  428 
lymphoma,  428 
pustules.     See  Anthrax. 
Mallein  test  for  glanders,  135 
Malocclusion,  trigeminal  neuralgia  and, 
290 
with  molars  in  contact  and  a  wide 
separation  between  anterior  teeth, 
operation  for,  401 
Malposition  of  teeth,  61-70 
Mandible,  unilateral  shortness  of,  cor- 
rection of,  398 
Mandibular  articulation,  trigeminal  neu- 
ralgia and,  286 
deformities  due  to  tumor  growths, 
surgical  correction  of,  402 


Mann's  exiicrimental  studies  on  shock 

and  hemorrhage,  54 
Marginal  gingivitis,  151 
Marriage,  syphilis  and.  111 
Martin's  artificial  denture  for  resected 
jaw,  388 
jaw,  389 
splint,  353 
Massage  in  treatment  of  trigeminal  neu- 
ralgia, 249 
Massetcrs,  tonic  sjiasm  of,  235 
Mastication,  muscles  of,  spasm  of,  235 
Maternal      impressions,    harelip      and, 

579 
Maxilla,  inferior,  fracture  of,  diagnosis 
of,  341 
etiology  of,  339 
treatment  of,  344 
superior,  fractures  of,  diagnosis  of, 
339 
etiology  of,  339 
treatment  of,  344 
Maxillae,  relation  of,  to  nasal  deformities, 
546 
diseases,  546 
separation  of,  author's  appliance  for, 
554 
clinical  results  of,  558 
improvement      in      breathing 

from,  563 
operation  for,  556 
tuberculosis  and,  563 
MaxiUary    bones,     destruction    of,     in 
syphilis,  121 
operation,   reduction  of  wide   cleft 

palate  by,  628 
sinuitis,  497 
sinus,  anatomy  of,  496 

circulatory  channels  of,  504 
cystocele  of,  529 
cysts  of,  497,  529 
dental,  529 
dentigerous,  529 
treatment  of,  529 
diseases  of,  495,  497-530 
acute  coryza  and,  497 
alveolar  abscess  and,  500 
of  bony  walls  of,  497 
bulging  of  walls  in,  505 
causes  of,  497,  498 
chronic  rhinitis  and,  498 
classification  of,  497 
deflection  of  nasal  septum 

and,  499 
dental  origin  of,  499,  500 
diagnosis    of,    differential, 
506 
from  interstitial  gingi- 
vitis, 507 
from  migraine,  507 
from  simple  empyema, 

507 
from  stomatitis,  508 
puncture  in,  509 
skiagraphs  in,  508 


724 


INDEX 


Maxillary   sinus,    diseases   of,  diagnosis 
of,  transillumination  in, 
508 
empyema  and,  503 
etiology  of,   nasal  factors 
in,  497 
oral  factors  in,  499 
frequency  of,  501 
intranasal  examination  in, 

506 
nasal  discharge  in,  506 
operations  and,  499 
polypi  and,  499 
operation  for,  alveolar,  510 
Caldwell-Luc,  519 
Canfield-Ballenger  an- 
trum, 522-524 
comparative  review  of, 

524-527 
Denker,  521 
intranasal,  511-513 
Kuster,  513-519 
oral  surgery  and,  527 
palatal,  511 
pain  in,  507 
prophylaxis  of,  509 
pus  in,  504 
symptoms  of,  504 
teeth  in,  507 
traumatism  and,  504 
treatment  of,  surgical,  510 
turgescence  of  "swell  bod- 
ies" and,  498 
"vicious    circle"    of    nose 
and,  498,  499 
empyema  of,  chronic,  497 
foreign  bodies  in,  497,  528 
diagnosis  of,  528 
removal  of,  528 
symptoms  of,  528 
treatment  of,  528 
infection  of,  from  nose,  499,  500 

from  teeth,  499 
infectious  diseases  of,  497,  528 
symptoms  of,  528 
treatment  of,  528 
pathological  changes  in,  503 
polypi  of,  497,  529 
tumors  of,  497,  529 
Median  phlegmon,  suprahyoid,  426 
Megaloglossia,  543 
Melanosarcoma,  468 
Melanotic  carcinoma,  476 
Meningitis,  cerebral,  218 
pathology  of,  218 
primary,  218 
secondary,  218 
symptoms,  218 
treatment  of,  220 
endemic,  218 

epidemic  cerebrospinal,  218 
septic,  218 
spinal,  214 
syphilitic,  218 
tubercular,  218 


Mercurial  necrosis  of  bone,  333 
diagnosis  of,  334 
pathology  of,  333 
symptoms  of,  333 
treatment  of,  334 
stomatitis  in  syphiUs,  118 
Mercurialism,  syphilis  and,  125 
Mercury,  administration  of,  in  syphilis, 
by  fumigation,  126 
internal,  124 
intramuscular,  125 
intravenous,  126 
by  inunction,  125 
Metabohc  pigmentation,  173 
Metabolism,  harelip  and,  579 
Metastasis  of  mumps,  414 
Microglossia,  542 
Microstomia,  573 
Migraine,  238 

diagnosis  of,  239 

from  disease  of  maxillary  sinus, 
507 
etiology  of,  238 
heredity  and,  238 
ophthalmic,  238 
prognosis  of,  239 
symptoms  of,  239 
treatment  of,  239 
visual  defects  and,  239 
MikuUcz's  disease,  418 

symptoms  of,  418 
Miliary  tubercles,  93 
Minor  trigeminal  neuralgia,  240 
Mixed  infection,  tuberculosis  and,  98 
Moro's  inunction  test  for  tuberculosis, 

101 
Morphin    and    atropin    before    general 

anesthesia,  34 
Motor  portion  of  trigeminal  nerve,  affec- 
tions of,  232 
Mouth,  floor  of,  diffuse  suppuration  of. 
See  Ludwig's  angina, 
mucous  membrane  of,  catarrh  of,  155 

diseases  of,  151 
relations  of,  to  spasmodic  neuroses, 

309 
wounds  of,  76 
Mucoid  carcinoma,  476 
Mucoperiosteal   flaps   in    operation   for 

cleft  palate,  623 
Mucous  glands,  cysts  of,  436 

membrane  of  mouth,  actinomycosis 
of,  162 
catarrh  of,  155 
diseases  of,  151 
glanders  of,  167 
leprosy  of,  168 
pemphigus  of,  171 
trigeminal   neuralgia   and, 

286 
tuberculosis  of,  162 
surfaces,  erysipelas  of,  191 
patch  in  syphilis,  118 
Multilocular  cysts,  441 
Multiple  neuritis,  193 


INDEX 


725 


Multiple  sclerosis,  220 
Mumps,  413 

complication  of,  414 

etiology  of,  413 

fever  in,  414 

metastasis  of,  414 

orchitis  and,  414 

pain  in,  414 

prognosis  of,  414 

symptoms  of,  414 

treatment  of,  414 
Murphy's  operation  in  ankylosis  of  jaws, 

377 
Muscles  in  hereditary  syphilis,  109 
Muscular  dystrophies,  203 
Myelinic  neuromas,  457 
Myelitis,  213 
Myeloid  sarcoma,  468 
Myomas,  461 

etiology  of,  462 

prognosis  of,  462 

syinptoms  of,  462 

treatment  of,  462 
Myositis,  536 
Myxomas,  467 

treatment  of,  468 
Myxosarcoma,  468 


N 


Nares,  contracted,  treatment  of,  550 
Nasal,  accessory  sinus,  495 

deformities,  correction  of,  by  sepa- 
ration  of   superior   maxillae, 
550 
relation  of,  to  maxilla?,  546 
surgical    treatment    of    harelip 
and,  585 
discharge    in    disease    of   maxillary 

sinas,  505 
diseases,  relation  of,  to  maxillse,  546 
factors  in  disease  of  maxillary  sinus, 

497-499 
polypi,   disease   of  maxillary  sinus 

and,  499 
septum,  deflection  of,  disease  of  max- 
illary sinus  and,  499 
deviation    of,     asymmetry    of 
hard  palate  and,  553 
treatment  of,  550 
double  development  of,  552 
splint  and  wire  tension   suture   in 
surgical  treatment  of  harelip,  598 
stenosis,  early  treatment  of  harelip 
in  infants  and,  584 
Naso-antral  wall,  removal  of,  in  intra- 
nasal operation  for  disease  of  maxil- 
lary sinus,  512 
Necrosis  of  bone,  arsenical,  334 
diagnosis  of,  336 
mercurial,  333 
pathology  of,  335 
phosphorus,  334 
symptoms  of,  335 


Necrosis  of  bone,  treatment  of,  336 
of  jaws,  326 

etiology  of,  326 
Neoplasms,  431 

classification  of,  432 
diagnosis  of,  433 
pathology  of,  432 
Nerve  anastomosis  for  facial  paralysis, 
298 
extraction  in  trigeminal  neuralgia, 

258 
stretching  in  trigeminal  neuralgia, 
258 
Nerve-blocking,  20 
Nerves,  injuries  of,  192 
regeneration  of,  192 
tumors  of,  195 
Nervous  system,   diseases   of,   affecting 

buccal  region,  192 
Neuralgia,  240 

trigeminal,  240 

ankylosis  of  roots  of  teeth  and, 

282 
arrested  development  and,  279 
bridge-work  and,  improper,  286 
carious  teeth  and,  286 
causes  of,  classification  of,  241 
classification  of,  241 
dental  aspects  of,  275 

factors  of,  diagnosis  of,  285 
skiagraphs  in,  287 
treatment  of,  289 
pulp  in,  destruction  of,  290 
diagnosis  of,  244 
diseases  of  dental  pulp  and,  282 
epileptiform,  240 
eruption  of  teeth  and,  285 
etiology  of,  241 
Gasserian  ganglion  in,  243 
hypercementosis  and,  281 
jaw  grinding  and,  280 
major,  240 

malocclusion     and,     correction 
of,  290 
soft-rubber  bit  for,  291 
mandibular    articulation    and, 

286 
minor,  240 

nasal  defects  and,  279 
nerve  extraction  in,  258 

stretching  in,  258 
neurectomy  in,  258 
neurotomy  in,  258 
oral    mucous    membrane    and, 

286 
pathology  of,  242 
pericementitis  and,  281 
pulpitis  and,  282 
symptomatic,  240 
symptoms  of,  243 
teeth  and,  eruption  of,  285 
extraction  of,  290 
number  of,  286 
temporomaxiUary     articulation 
and,  292 


726 


INDEX 


Neuralgia,    trigeminal,    tooth    grinding 
and,  280 
treatment  of,  248 
castor  oil  in,  249 
exposure  of  first  trigeminal 

branch  in,  260 
gelsemium  in,  249 
by  injection  of  alcohol,  251 
technic    of,    251- 
258 
of  osmic  acid,  250 
massage  in,  249 
medicinal,  249 
psN^chotherapeutic,  249 
surgical,  258 
Neurasthenia,  314 

dental  factors  in,  315 
Neurectomy  in  trigeminal  neuralgia,  258 
Neuritis,  192 

classification  of,  192 

etiology  of,  193 

facial  paralysis  and,  294 

interstitial,  pathology  of,  193 

multiple,  193 

optic,  228 

parenchymatous,      pathology      of, 

193 
pathology  of,  193 
peripheral,  193 
prognosis  of,  194 
segmental  periaxillary,  pathology  of, 

193 
symptoms  of,  193 
treatment  of,  194 
Neurofibromatosis,  460 
Neuroma,  195,  196,  455 
amputation,  457 
amyeUnic,  457 
etiology  of,  457 
false,  456 
ganglionic,  457 
myelinic,  457 
plexiform,  456 
prognosis  of,  457 
symptoms  of,  457 
treatment  of,  457 
Neuroses,  spasmodic,  303 
Neurotomy  in  trigeminal  neuralgia,  258 
Nevus,  462 
Nigrities  lingua;,  535 
Ninth  cranial  nerve.     See  Glossopharyn- 
geal nerve. 
Nitrous  oxide  gas  and  oxygen  in  general 
anesthesia,  28 
oxide-ox>^gen-ether  sequence  in  gen- 
eral anesthesia,  31 
Nodular  lymphangioma  of  tongue,  541 
Noma.     See  Stomatitis,  gangrenous. 
Normal    salt   solution,    infasion    of,    in 

hemorrhage,  47 
Nose  defects  after  operation  for  hare-Up, 
correction  of,  610 
infection   of   maxillary   sinus   from, 
499,  500 
Novocain  in  local  anesthesia,  18 


Odontom.\s,  444 

classification  of,  444 
composite,  448 
diagnosis  of,  448 
epithelial,  445 
etiology  of,  444 
fibrous,  445 
follicular,  441,  445 

compound,  448 
prognosis  of,  449 
radicular,  447 
treatment  of,  449 
CEdema.     See  Edema. 
O'idium  albicans,  160 
Olfactory  nerve,  lesions  of,  223 
Operative  field,  control  of,  in  removal  of 

impacted  teeth,  75 
Ophthalmic  migraine,  238 

nerve,    operation    for    exposure  of, 

260 
test  for  tuberculosis,  101 
Ophthalmoplegia,  230 
Opsonic  index  test,  Wright's,  for  tuber- 
culosis, 101 
Optic  nerve,  anemia  of,  227 
atrophy,  228 
edema  of,  227 
hyperemia  of,  227 
lesions  of,  227 
neuritis,  228 
Oral  deformities,  etiological  factors  of, 
549 
'  factors  in  disease  of  maxillary  sinus, 
499 
hygiene  in  syi)hiUs,  124 
region,  embryonic  sections  of,  547- 
549 
Orchitis,  mumps  and,  414 
Osmic  acid,  injection  of,  in  trigeminal 

neuralgia,  250 
Osseous  apposition,  318 

resorption,  318 
Osteitis  deformans,  324 

treatment  of,  324 
sicca  tuberculosa,  97 
Osteochondritis,  hereditary  svphilis  and, 
109 
syphiUtic,  332 
Osteogenesis,  318 

imperfecta,  320 
Osteomas,  459 

prognosis  of,  460 
symptoms  of,  459 
treatment  of,  460 
Osteomalacia,  318 
Osteomyelitis,  326 

tuberculous,  97 
Osteoperiostitis,  325 

syphilis  and,  121 
Osteoplastic  res:!ction  of  upper  jaws,  305 
Osteosarcoma,  468 

()ttcnl)erg's    methocl    of    transfusion    (,f 
blood,  42,  43 


INDEX 


727 


Pachymeningitis    cervicalis    hypertro- 

phica,  213 
Palatal  operation  for  disease  of  maxillary 

sinus,  511 
Palate  bones,  fracture  of,  in  operation 
for  deft  palate,  622 
cleft,  576.     See  also  Harelip, 
hard,    asymmetry  of,   deviation   of 
nasal  septum  and,  553 
shortening  of,  defects  of  speech 

due  to,  648 
syphilis  and,  119 
soft,  syphihs  and,  119 
Palatograms,  Kingslev's,  655 
Palsy,  bulbar,  224 

defective  speech  in,  225 
diagnosis  of,  22o 
etiology  of,  224 
pathology  of,  225 
symptoms  of,  225 
treatment  of,  226 
"Papilledema,"  227 
Papilloma,  450 

etiology  of,  450 
prognosis  of,  451 
symptoms  of,  451 
of  tongue,  539 
treatment  of,  451 
varieties  of,  450 
villous,  450 

intracystic,  450 
Paralymphadenitis,  427 
Paralysis,  abducens,  229,  230 

of  accessory  spinal  nerve,  302 
acute    atropliic    spinal.     See  Polio- 
myelitis, anterior, 
progressive,  211 
cerebral  spastic,  215 
chronic  atrophic.   See  Poliomyelitis, 

anterior,  chronic, 
facial,  293 

basal  disease  of  brain  and,  293 
fractures  of  skull  and,  293 
constitutional  disease  and,  294 
diagnosis  of,  295 
emotional  shock  and,  294 
etiology  of,  293  | 

exposure  and,  293 
localization  of  lesion  in,  294 
nerve  anastomosis  for,  298 
neuritis  and,  294 
neuropathic  tendency  and,  293 
poliomyelitis  and,  294 
polyneuritis  and,  294  , 

prognosis  of,  295  ' 

spasmodic  contraction  in,  294 
suppurative  ear  disease  and,293 
symptoms  of,  294 
trauma  and,  293 
treatment  of,  297 
.surgical,  297 
of  hypoglossal  nerve,  302 
infantile.  See  Poliomj'elitis,  anterior.  , 


Paralysis,      Landry's.     See      Paralysis, 
acute  progressive, 
of  motor  portion  of  trigeminal  nerve, 

232 
patheticus,  229 

retrogressive.    See  Poliomyelitis,  an- 
terior, 
of  sixth  cranial  nerve,  229 
in  syringobulbia,  198 
Parasitic  cysts,  444 
Parasitic-mycotic  stomatitis,  180 
ParasyphiUdes,  114 
Parenchymatous  neuritis,  pathologv  of, 

193 
Paresthesia  of  trigeminal  nerve,  236 
Parotid  tumors,  bilateral,  417 
Partsch's  artificial  jaw,  390 
PatheticvLS  paralysis,  229 
Pathological  dentition,  59 
fractures  of  jaw,  339 
PeUagra,  178 
Pemphigus,  171 
Percy's  method  of  transfusion  of  blood, 

43 
Pericementitis,  trigeminal  neuralgia  and, 

281 
Periosteal  cysts  of  jaws,  439 
diagnosis  of,  441 
etiology  of,  439 
symptoms  of,  441 
treatment  of,  441 
Periosteum,  ch.seases  of,  324 
Periostitis,  324 

acute  simple,  324 
hereditar}'  syphihs  and,  109 
purulent,  325 
Peripheral  neuritis,  193 
Perversion  of  smell,  227 
Petit  mal,  307 
Pharyngeal  adenoids,  421 

tonsil.     See  Adenoids. 
Phlegmon,  suprahyoid  median,  426 
symptoms  of,  426 
treatment  of,  426 
Phlegmonous  glossitis,  533 

stomatitis,  162 
Phosphorus  necrosis  of  bone,  334 
pathology  of,  334 
symptoms  of,  334 
treatment  of,  334 
Pigmentation,  hematogenous,  172 
hepatogenous,  173 
metabolic,  173 

of  mucous  membranes  of  mouth,  172 
treatment  of,  173 
Pigmented  sarcoma,  476 
Pike  and  Coombs's  studies  on  shock  and 

hemorrhage,  54 
Pituitary  bod}^,  diseases  of,  224 
extract  in  hemorrhage,  41 
Plexiform  angiomas,  463 
angiosarcoma,  468 
neuromas,  456 
Pneumococcus    infection    of    accessory 
nasal  sinuses,  504 


728 


INDEX 


Pneumonokoniosis,  172 
Poisons,  82 

Poliomyelitis,  acute  anterior,  198 
anterior,  198 
chronic,  201 
diagnosis  of,  200 
epidemic  cases  of,'  199 
etiology  of,  198 
facial  paralysis  and,  293 
neutralization  of  virus  of,  200 
prognosis  of,  200 
sporadic  cases  of,  199 
symptoms  of,  199 
treatment  of,  200 
Polyneuritis,       facial      paralysis      and, 

294 
Polypi  of  maxillarj'  sinus,  497,  529 
Port-wine  mark,  462 
Postnasal  tonsils.     See  Adenoids. 
Potassiuin     iodide     and     mercury     in 

syphilis,  126 
Pott's  disease,  332 
Premaxilla,  reduction  of,  604 
incisions  for,  605 

von  Lagenbeck's,  605 
Pressure  atrophy  of  bone,  319 

intracranial,  215 
Primary  symptoms  of  sj'pliilis,  112 
Proctoclj'sis  in  hemorrhage,  39,  49 
Progressive  lipodystrophy,  317 

lymphadenoid  hyperplasia,  428 
muscular  atrophy,  201 

diagnosis  of,   from  amyo- 
trophic lateral  sclerosis, 
203 
paralysis,  acute,  211 
Proliferation  cysts,  441 
Proliferous  cysts,  441 
Pseudoleukemia,  428,  466 
Pseudomembranous  glossitis,  535 

stomatitis,  161 
Psoriasis  of  tongue,  535 
Ptyahsm,  417 
Pulp,  dental,  diseases  of,  282 

trigeminal   neuralgia   and, 
282 
sensitiveness  of,  to  cold,  288 

to  heat,  288 
temperature  test  of,  288 
nodules,   trigeminal  neuralgia  and, 
283 
Pulpitis,  282 

Puncture  in  diagnosis  of  disease  of  maxil- 
lary sinus,  509 
Purpura,  183 

hemorrhagica,  183 

diagnosis   of,    from   scorbutus, 
184 
nautica,  184 
Pus  in  disease  of  maxillary  sinus,  505 
Pustule,  malignant.     See  Anthrax. 
Putrid  intoxication,  82 
Pyemia,  S3 

Pyorrhea  salivalis,  412 
Pyrexia,  84 


QuiNiNE-xjREA    hydrochloride    in    local 
anesthesia,  19 


Radicular  odontoma,  447 

Radium  in  treatment  of  carcinoma,  483 

Ranula,  436 

diagnosis  of,  437 
etiology  of,  437 
prognosis  of,  437 
of  salivary  glands,  420 
symptoms  of,  437 
treatment  of,  437 
Receding  chin,  operation  for,  402 
Rectal  anesthesia,  29 
Regeneration  of  bone,  319 
Resection  of  jaws,  lower,  384 
complete,  385 
partial,  384 
prognosis  of,  392 
retention  of  divided  frag- 
ments, 387 
temporary,  384 
upper,  393 

complete,  394 

exposure  of  arteries  in,  405 

operative  dangers  in,  402 

osteoplastic,  395 

partial,  394 

prognosis  of,  404 

removal  of  both  superior 

maxillse,  403 
treatment    of,    postopera- 
tive, 403 
Resorption  fever,  84 
Retention   appliances   in   operation   for 
cleft  palate,  624 
cysts,  435 

of  tongue,  536 
Retrogressive  paralysis.    See  Poliomj-eli- 

tis,  anterior. 
Rhinitis,  acute,  disease  of  maxillary  sinus 

and,  497 
Rickets,  320 
Riga's  disease,  536 
Rodent  ulcer,  476 


St.  ViTus's  dance.     See  Chorea. 
Saliva,  pathological  indications  of,  407 
Sahvary  calcuh.     See  Salivary  stones, 
ducts,  fistula  of,  diagnosis  of,  from 
saUvar}^  gland  fistula,  409 
foreign  bodies  in,  410 

diagnosis  of,  411 
pain  in,  410 
symptoms  of,  410 
treatment  of,  411 
inflamm.ation     of.     See    Sialo- 
dochitis. 


INDEX 


729 


Salivary  ducts,  injuries  of,  408 
fistula,  409 
duct,  409 

diagnosis  of,  from  salivary 

gland  fistula,  409 
permanent    treatment    of, 

409 
treatment  of,  409 
etiologv  of.  409 
gland.  409 

diagnosis  of.  from  salivary 

duct  fistula,  409 
treatment  of,  409 
sjTnptoms  of,  409 
gland,  actinomj'cosis  of,  420 
congenital  defects  of,  407 
cysts  of,  420 
diseases  of,  407 

fistula,  diagnosis  of,  from  sali- 
vary duct  fistula,  409 
hypersecretion  from  417 
inflammation  of,  413,  416 
injuries,  408 

fixation  of  jaws  in,  408 
treatment  of,  408 
ranula  of.  420 
sypliilis  of,  420 
tuberculosis  of,  420 
tumors  of,  420 
stones,  411 

diagnosis  of,  412 
etiology  of,  411 
occurrence  of,  411 
sjTnptoms  of,  411 
treatment  of,  412 
Salvarsan  for  sj-philis,  127 
Salt  solutions,  hypertonic  and  isotonic, 

671 
Sapremia,  82 
Sarcoma,  468 
alveolar.  468 
giant-cell,  468 
myeloid,  468 
pigmented,  476 
of  tongue,  542 
treatment  of,  482 
"SatelHte  gland"  in  syphilis,  116 
Sauer's  splint,  353 
Scars,   removal  of,   after  operation  for 

harelip,  610 
Schleich's  infiltration  anesthesia,  20 
Sclerosis,  amyotrophic  lateral.  201 
diagnosis  of,  202 

from  progressive  mus- 
cular      atrophy, 
203 
etiology  of,  201 
symptoms  of,  201 
treatment  of,  203 
multiple,  220 
of  tongue  in  sj-philis,  119 
Scopolamine     anesthesia,     partial,     for 
aged,  19 
morphin,  anesthesia  and,  34 
Scorbutus,  184 


Scorbutus,    diagnosis  of,  from    purpura 
hemorrhagica,  184 
infantile,  185 

diagnosis  of,  189 
etiology  of,  185 
symptoms  of,  186 
Scurvj',  184 

Second  cram'al  nerve.     See  Optic  nerve. 
Secondary  symptoms  of  syphilis,  112 
Segmental    periaxillary    neuritis,    path- 
ology of,  193 
Sensory    portion    of    trigeminal    nerve, 

affections  of,  236 
Separation  of  maxillge,  operation  for,  550, 

555-558 
Sepsis,    prevention    of,    in    wounds    of 

mouth,  78 
Septic  fever,  85 

autogenous  bacterins  in,  90 
combined  venesection  and  in- 
travenous saline  transfusion 
in,  87-89 
cryptogenetic,  85 
direct  transfusion  of  blood  in, 

86 
etiology  of,  85 
hj-podermcctysis  in,  86 
intravenous  saline  transfusions 

in,  86 
pyemic  type  of,  86 
septicemic  tj^je  of,  85 
symptoms  of,  85 
toxemic  tj-pe  of,  85 
treatment  of,  86 
vaccine  therapy  in,  88 
intoxication,  82 
meningitis,  218 
Septicemia,  S3 
Septum,  nasal,  deflection  of,  disease  of 

maxillary  sinus  and,  499 
Seventh  cranial  nerve.     See  Facial  nerve. 
Shock,  52 

after-treatment  of,  56 

bandaging  in,  57 

carbon  dioxide  content  of  blood  and, 

57,  58 
causes  of,  operative,  53 

psj'chic,  52 
cold  and,  53 
etiolog}^  of,  52 
excitement  and,  53 
hemorrhage  and,  53 
infections  and,  53 
symptoms  of,  55 
treatment  of,  55 

prophj-Iactic,  55 
Sialoadenitis,  413 
infantile,  415 
Sialodochitis,  412 
diagnosis  of,  413 
etiology,  412 
sj-mptoms  of,  412 
treatn.ent  of,  413 
Sialolithiasis.     See  Sahvary  stones. 
Sialorrhea,  417 


730 


INDEX 


Simple  adenia,  428 

hemangioma  of  tongue,  540 
wounds,  76 
Sinuitis,    maxillary,    catarrhal,      acute, 
497 
symptoms  of,  504 
chronic,  497 

symptoms  of,  504 
suppurative,  acute,  497 

symptoms  of,  505 
chronic,  497 

symptoms  of,  505 
Sinus,  accessory  nasal,  495,  501 
ethmoidal,  501 
frontal,  501 
maxillary,  495 
sphenoidal,  501 
Sinuses,  venous  thrombosis  of,  221,  222 
Sixth  cranial  nerve,  lesions  of,  229 

paralysis  of,  229 
Skiagraphs  in    diagnosis   of   disease    cf 

maxillary  sinus,  508 
Skin  warts,  450 

Skull,  basal  fractures  of,  facial  paralysis 
and,  293 
fenestration  of,  for  epilepsj',  309 
Smell,  loss  of,  227 

perversion  of,  227 
Soft  chancre.     See  Chancroid. 
Somnoform  in  general  anesthesia,  32 
Sore  throat  in  sypliilis,  118 
Spasm,  facial,  306 

treatment  of,  306 
habit,  of  trigeminal  nerve,  235 
of  muscles  of  mastication,  235 
tonic,  of  masseters,  235 
Spasmodic  affections  of  trigeminal  nerve, 
235 
neuroses,  303 

delayed  eruption  of  teeth  and, 

310 
"periods  of  stress"  and,  309 
relations  of  mouth  to,  309 
of  teeth  to,  309 
Spastic  paralysis,  cerebral,  215 
Speech,  defective,  anatomical  defects  and, 
correction  of,  653 
in  bulbar  paralysis,  225 
cleft  palate  and,  644 
due  to  early  operation  for  cleft 
palate,  647 
to  flexibility  of  tissues,  648 
to  imperfect  development, 

653 
to  insufficient  velum,  648 
to  nasal  maldevelopment, 

648 
to  shortening  of  hard  pal- 
ate, 648 
improvement  of,  648 

by  correction  of  deformed 
lips,  649 
of  dental  arch,  649 
etiology  of,  653 
not  due  to  cleft  palate,  653 


Speech,  defective,  training  for,  auditory 
motor  control  in,  658 
coordination   in,   accuracy 
of,  658 
precision  of,  658 
general  i)rinciples  of,  657 
ideomotor  control  in,  658 
movement  in,  accuracy  of, 
658 
force  of,  658 
muscular,  quickness  of, 

658 
precision  of,  658 
reflex  tonus  in,  657 
response  in,  quickness  of, 

658 
simple  methods  of,  656 
voluntary  control  in,  658 
treatment  of,  author's  method, 
653 
effect  of  early  treatment  of  hareUp 
in  infants  upon,  585 
Sphenoidal  sinus,  501 
Spinal  accessory  nerve,  lesions  of,  302 
paralysis  of,  302 
cord,  diseases  of,  197 
meningitis,  214 
Spirocheta  paUida,  107 

identification  of,  121 

Burrie's  method  of,  121 
Splenic  fever.     See  Antlirax. 
Sphnts,  interdental,  347-349 
Squamous  epithelioma,  474 
Staphylorrhaphy,  621 

instruments,  author's  set  of,  640,  641 
"Strawberry"  tongue,  531 
Stein's  antrum  chisel,  513 
Steno's  duct,  407 

foreign  bodies  in,  410 
Stenosis,  nasal,  early  treatment  of  hare- 
Up in  infants  and,  584 
Stomatitis,  151 
aphthous,  155 

etiology  of,  155 
symptoms  of,  155 
treatment  of,  156 
catarrhalis,  155 
etiology  of,  155 
symptoms  of,  155 
treatment  of,  155 
diagnosis  of,  from  disease  of  maxil- 
lary sinus,  508 
gangrenous,  157 
etiology  of,  158 
prognosis  of,  160 
symptoms  of,  158 
treatment  of,  160 
gonorrheal  ulceromembranous,  171 
etiology  of,  171 
s^TTiptoms  of,  171 
treatment  of,  171 
leukemic,  162 

blood  count  in,  167 
mercurial,  in  syphilis,  118 
parasitic-mycotic,  160 


INDEX 


731 


Stomatitis,    parasitic-mycotic,   etiology 
of,  160 
sjnnptoms  of,  100 
treat iiieiit  of,  KiO 
phlegmonous,  1G2 
pseudomembranous,  IGl 
simplex,  154 

symptoms  of,  154 
treatment  of,  155 
ulcerative,  156 

etiology  of,  156 
prognosis  of,  157 
symptoms  of,  156 
treatment  of,  157 
Stomatoplasty,  574 
Stones,  salivary,  411 
Stoppany's  artificial  jaw,  391 
Stovain  and  novocain  in  local  anesthesia, 

18 
Strauss's  test  for  glanders,  135 
Styptics  in  hemorrhage,  39 
Subcutaneous  wounds,  78 
Sublingual  cysts,  436 
Submaxillary     celluHtis,     diffuse.       See 

Ludwig's  angina. 
Subperiosteal  fractures  of  jaws,  339 
Supernumerary  teeth,  61 
Suppurative  ear  disease,  facial  paralysis 
and,  293 
maxillary  sinuitis,  acute,  497 
chronic,  497 
Suprahyoid  median  phlegmon,  426 
Surgical  wounds,  76 
"Swell  bodies"  turgescence  of,  disease 

of  maxillary  sinus  and,  498 
Symptomatic  erythema,  177 
Synovitis,  366 

monarticular,  366 
polyarticular,  366 
treatment  of,  366 
Syphihs,  107 

abortion  of,  123 
acquired,  110 

etiology  of,  1 10 

extragenital  inoculation  in,  110 
immunity  to,  112 
marriage  and,  111 
symptoms  of,  112 
primary,  112 
secondary,  112 
tertiary,  114 
arsenic  for,  127 
of  bone,  332 
chancre  in,  116 
chronic  glossitis  and,  532 
diagnosis  of,  114 
clinical,  115 
differential,  117 
laboratory,  121 
method  of,  115 
epithelioma  and,  119 
gumma  and,  119 
hard  palate  and,  119 
hereditary,  107 
bones  in,  109 


Syphilis,  hereditary,  CoUes's  law  in,  107 
dactylitis  and,  109 
joints  in,  109 
lymph  nodes  in,  109 
muscles  in,  109 
osteochondritis  and,  109 
periostitis  and,  109 
symptoms  of,  108 
teeth  in,  108 

Fournier's,  109 
Hutchinson's,  108 
iodism  and,  126 
leukoplakia  in,  118 
lymph  nodes  in,  1 16 
maxillary  bones  in,  destruction  of, 

121 
mercurial  stomatitis  in,  118 
mercuriaUsm  and,  126 
mercury  for,  administration  of,  124 
by  fumigation,  126 
internal,  124 
intramuscular,  125 
intravenous,  126 
by  inunction,  125 
mucous  patch  in,  118 
oral  hygiene  in,  124 

symptoms  of,  secondary,  118 
tertiary,  118 
osteoperiostitis  and,  121 
potassium  iodide  and  mercury  in, 

126 
primary  sore  of,  116 
prophylaxis  of,  123 
of  saUvary  glands,  420 
salivation  in,  126,  420 
salvarsan  for,  127 
"satellite  gland"  in,  116 
"606"  for,  127 
soft  palate  and,  119 
sore  throat  in,  1 18 
Spirocheta  pallida  in,  identification 
of,  121 
Burrie's    method    of, 
121 
symptoms  of,  108,  109,  112-114 
of  third  generation,  110 
tongue  in,  118 

gumma  Of,  119 
sclerosis  of,  119 
treatment  of,  123 

early,  123 
Wassermann  test  for,  121 
Syphilitic  dystrophies,  114 
meningitis,  218 
osteochondritis,  332 
"Syringobulbia,"  225 
Syringomyelia,  197 
analgesia  in,  197 
diagnosis  of,  198 
etiology  of,  197 
muscular  atrophy  in,  198 
paralysis  in,  198 
symptoms  of,  197 
treatment  of,  198 
trophic  disturbance  in,  198 


732 


INDEX 


Talbot's  iodoglycerol,  153 

"Tapir    mouth"    in    muscular    dystro- 

pliies,  204 
Teeth,  carious,  trigeminal  neuralgia  and, 
286 
encystment  of,  61 
eruption  of,  60 

convulsions  and,  303 

delayed,     spasmodic    neuroses 

and,  310 
trigeminal  neuralgia  and,  279- 
291 
extraction  of,  serious  accidents  in, 

71 
Fournier's,  109 
Hutchinson's,  108 
impacted,  61-76 
infection  of  maxillary  sinus  from, 

4S9 
malposition  of,  61-76 
relations  of,  to  spasmodic  neuroses, 

309 
roots  of,  exsection    of,  in    dentoal- 

veolar  abscesses,  146 
supernumerary,  61 
temperature  test  for,  288 
Telangiectasis,  462 
Temperature  test  for  teeth,  288 
Temporomandibular  articulation,  affec- 
tions of,  359 
alterations  in  forms  of,  360 
ankylosis  of,  366 
bony,  374 
fibrous,  368 
temporary,  367 
arthritis  of,  365 
arthrodesis  of,  383 
description  of,  359 
dislocation  of,  360 

chronic,  364 
synovitis  of,  366 
Tenth  cranial  nerve.     See  Vagus  nerve. 
Tertiary  symptoms  of  syphilis,  114 
Tetanus,  90 
acute,  91 
antitoxin,  93 
bacillus  of,  90 
cephaUc,  91 
chronic,  91 
diagnosis  of,  92 
etiology  of,  90 
frequency  of,  90 
prognosis  of,  92 
prophylaxis  of,  94 
treatment  of,  92 
Third  cranial  nerve,  lesions  of,  229 
Thrombosis,  cerebral,  215 

of  venous  sinuses,  221,  222 
Thrush,  160.     See  also  Stomatitis,  para- 

sitic-mycotic. 
Thymus  gland,   dried,  in  treatment  of 

carcinoma,  483 
Thyroglossal  cysts,  538 


Thyroid  extract  in  treatment  of   carci- 
noma, 483 
tumors,  accessory,  455 
Tic,  306 

diagnosis  of,  from  facial  spasm,  306 
douloureux,  244 
"aura"  in,  246 
diagnosis  of,  247 
pain  in,  245 
symptoms  of,  244 
motor,  246 
sensory,  245 
vasomotor,  247 
treatment    of,    248.     .See    also 
Trigeminal  neuralgia,  treat- 
ment of. 
treatment  of,  306 
Tinnitus  aurium,  300 

diagnosis  of,  300 

differential,  301 
etiologj'  of,  300 
prognosis  of,  301 
relation  of,  to  oral  diseases,  300 
treatment  of,  301 
Tongue,  absence  of.     See  Aglossia, 
actinomycosis  of,  536 
adenoma  of,  539 
adherent,  545 
atrophy  of,  535 
base  of,  cysts  of,  537 
bifid,  542 
carcinoma  of,  542 
chancre  of,  116 
cysts  of,  536 

cysticercus,  537 
dermoid,  537 
echinococcus,  537 
hydatid,  537 
retention,  536 
treatment  of,  537 
diseases  of,  531 
endothehoma  of,  542    . 
fibroma  of,  539 

in  foot-and-mouth  disease,  536 
furring  of,  531 
gangrene  of,  535 
geographical,  531 
glanders  of,  536 
hemangioma  of,  540 
cavernous,  540 
simple,  540 
treatments  of,  540 
varieties  of,  540 
inflammation  of.     See  Glossitis, 
leprosy  of,  536 
hpoma  of,  538 
lobulated,  542 
long,  543 

lymphangioma  of,  541 
cavernous,  542 
nodular,  541 
malformations  of,  542 
nervous  affections  of,  535 
papilloma  of,  539 
psoriasis  of,  535 


INDEX 


733 


Tongue,  sarcoma  of,  542 
"strawberry,"  531 
in  sypliilis,  118 
tremor  of,  535 
tumors  of,  536 
Tongue-tie,  543 

symptoms  of,  543 
treatment  of,  544 
Tonic  spasm  of  masseters,  235 
Tonsils,  epipharyngeal.     See  Adenoids, 
hypertrophy  of,  421 
pharyngeal.     See  Adenoids, 
postnasal.     See  Adenoids. 
Tooth  grinding,  trigeminal  neuralgia  and, 

280 
Tourniquet  in  hemorrhage,  39 
Toxemia,  82,  83 

early  treatment  of  harelip  in  infants 
and,  583 
Transfusion  of  blood  in  hemorrhage,  39, 
41-47 
cannula.  Brewer's  glass,  43 

Crile's,  42 
direct,  41 

of  blood  in  septic  fever,  86 
indirect,  43 

technic  of,  46 
intravenous  saline,  in  septic  fever,  86 
and  venesection  in  septic 
fever,  86-89 
treatment  of  hemophiha  by,  49 
Transillumination  in  diagnosis  of  disease 

of  maxillary  sinus,  508 
Transplantation  of  tissue  in  operation 

for  cleft  palate,  627 
Transzygomatic    route    for   removal    of 

Gasserian  ganglion,  270 
Trauma  of  mucous  membranes  of  oral 

region,  173 
Traumatic  fever,  84 
Tremor  of  tongue,  535 
Trigeminal  nerve,  anesthesia  of,  237 
etiology  of,  237 
symptoms  of,  237 
degeneration  of,  232 
diseases  of,  230 
first  branch,  exposure  of,  260 
general  consideration  of,  230 
hyperesthesia  of,  236 
infraorbital  division  of,  expos- 
ure of,  260 
irritation    of,    impacted    teeth 

and,  235 
motor  portion  of,  affections  of, 
232 
habit  spasm  and,  235 
spasmodic,  235 
treatment  of,  235 
paralysis  of,  232 

hemiatrophy    of    face 
in,  233 
paralysis  of,  herpes  zoster  and, 

235 
paresthesia  of,  236 
regeneration  of,  232 


Trigeminal  nerve,  second  branch,  expos- 
ure of,  260 
sensory  portions  of,  affections 
of.  236 
headache  in,  238 
pain  in,  238 
third  branch  of,   exposure  of, 
265-268 
neuralgia,  240 

Krause's  operation  for,  262 
pulp  nodules  and,  283 
treatment  of  exposure  of  third 
trigeminal  branch  in,  265 
by  extracranial  operations 

at  base  of  skull,  268 
by   removal   of   Gasserian 
ganglion,  269 
Trismus  in  actinomycosis,  132 
Trophic  changes,  317 
Tubercular  meningitis,  218 
Tuberculin  test  for  tuberculosis,  100 
Tuberculosis,  94 
bacillus  of,  94 
of  bone,  97,  331 

eburnated  infarct  in,  97 
periosteal,  332 
diagnosis  of,  98 
general,  99 
etiology  of,  94 
frequency  of,  105 
heredity  and,  96 
inoculation  of,  direct,  95 
intestinal,  95 
of  joints,  97 
miliary  tubercles  in,  96 
mixed  infection  and,  96 
of  mucous  membrane  of  mouth,  162 
organs  affected  in,  96 
pathology  of,  96 
portals  of  entrance  of,  95 
prophylaxis,  101 
of  salivary  glands,  420 
separation  of  maxillae  and,  563 
special  forms  of,  96 
summary  of,  104 
symptoms  of,  97 

general,  99 
tests  for,  100 

cutaneous,  von  Pirquet's,  100 
inunction,  Moro's,  101 
ophthalmic,  101 
tubercuUn,  100 
Wright's  opsonic  index,  101 
treatment  of,  103 
Tubular  adenoma,  453 
Tubulated  epithelioma,  474 
Tumor  growths,  mandibular  deformities 

due  to,  surgical  correction  of,  402 
Tumors,  431 

bilateral  parotid,  419 
of  brain,  222 
connective-tissue,  457 
epithelial,  adult,  444 
fatty,  457 
malignant,  468 


734 


INDEX 


Tumors  of  maxillary  sinus,  497,  529 

of  nerves,  1£5 

of  salivary  glands,  420 

of  tongue,  536 

wart,  450 
Twelfth  cranial  nerve.     See  Hypoglossal 
nerve. 


Ulcer,  rodent,  476 

Ulcerative  stomatitis,  156 

Ulceromembranous  cellulitis,  gonorrheal, 
171 

Ultra\iolet  rays  in  treatment  of  carcino- 
ma, 483 

Uranoplasty,  021 

Uranorrhaphy,  620 

Uranostaphylorrhaphy,  621 

Urticaria,  178 


Vaccine  therapy  in  septic  fever,  88 

Vagus  nerve,  lesions  of,  301 

Vegetations,  adenoid.     See  Adenoids. 

Velum,    insufficient,    defects    of   speech 
due  to,  648 

Venesection  and  intravenous  saline  trans- 
fusion in  septic  fever,  86-88 

Venous  sinuses,  thrombosis  of,  221,  222 

"Vicious  circle"  of  nose,  disease  of  maxil- 
lary sinus  and,  498,  499 

Villous  papilloma,  450 

intracystic,  450 

Vincent's  angina,  169 

etiology  of,  169 
treatment  of,  169 

Virus  of  anterior  poliomyelitis,  neutraU- 
zation  of,  201 

Von  Langenbeck's  incisions  for  reduction 
of  premaxilla,  605 

Von  Pirquet's  cutaneous  test  for  tuber- 
culosis, 100 


W 


War  injuries,  immediate  treatment  of, 
671 
principles   of   plastic  and   oral 
surgery  applied  to,  673 


Wart  tumors,  450 
skin,  450 
soft,  450 
Wassermann  test,  121 

technic  of,  121,  122 
Wharton's  duct,  407 

foreign  bodies  in,  410 
inflammation  of,  412 
"White  swelUng,"  97,  332 
Whitehead's   operation   for  removal  of 

tongue,  489 
Woolsorters'  disease.     See  Anthrax. 
Wound  fever,  aseptic,  84 
Wounds,  76 

definition  of,  76 
gunshot,  of  face  and  jaws,  688 
heahng  of,  by  adhesion  by  granulat- 
ing surface,  77 
by  first  intention,  77 
by  granulation,  77 
by  immediate  union,  76 
by  second  intention,  77 
by  third  intention,  77 
of  mouth,  76 

coaptation  of  wound  surfaces 

in,  to  promote  healing,  77 
control  of  hemorrhage  in,  77 
drainage  in,  78 
dressings  for,  77,  78 
hemorrhage    from    ligation    of 
external  carotid  in,  80 
treatment  of,  79-81 
prevention  of  jihysiological  ac- 
tion in,  78 
sepsis  in,  77 
treatment  of,  77 
repair  of,  76 
varieties  of,  76 
Wright's  opsonic  index  test  for  tubercu- 
losis, 101 


Xerostoma,  417 

X-rays  in  treatment  of  carcinoma,  484 
results  of  use  of,  491 


Zinc   oxide   adhesive   strip   in   surgica 
treatment  of  harelip,  592 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

'  '^^  i  ..^i 

i  ^  r 

C28(23g)MI0O 

1918 


RD  523  B81  1918  C.I 

rl  malform 


2002231484 


